Take Charge! Follow up, Diagnostic, and Treatment Training
(ODH Form No. 274C) Training
Slide 1 - Cover Slide
Welcome to the Take Charge! Follow up, Diagnostic, and Treatment (ODH Form No. 274C)
Training.
Slide 2 - Before Proceeding with Training
Please have the Take Charge! Follow up, Diagnostic, and Treatment (ODH Form No.
274C) and the 274C Additional Information document in front of you for easy reference.
Plan on completing and returning the skill assessment and allow approximately
30 minutes for this training.
Find a quiet place to compete the training. Do not work as a group.
Slide 3 - Who is required to take the ODH Form No. 274C Training?
Who is required to complete the ODH Form No. 274C Training at your facility?
The following individuals at your facility who need to take the training include patient
navigators, administrative assistants, medical assistants, billing/invoice personnel along
with any licensed healthcare providers such as DO, MD, Physician Assistant, Nurse
Practitioner, RN, LPN, etc. who provide Take Charge! services to eligible clients.
The training is for all individuals in your facility that assist with Take Charge! related
clients and services.
Slide 4 - Training Goal & Objectives
The goal of this training is to provide an opportunity to gain knowledge and skill in
completion of the Take Charge! ODH Form No. 274C.
Once you have completed this training, you should be able to recall the steps for
completion of the ODH Form No. 274C and correctly complete the revised ODH Form
No. 274C.
Slide 5 - Take Charge! Follow up, Diagnostic, and Treatment (ODH Form No.
274C)
This is a picture of the ODH Form No. 274C which was revised June 2019. We will
review the form in its entirety.
Take Charge! Follow up, Diagnostic, and Treatment Training
(ODH Form No. 274C) Training
Slide 6 - Background Information
The 274C is a 2 page 2 part form is produced on no carbon required paper (NCR), once
all of the current NCR forms have been used the ODH Form 274C will be printed on
regular paper.
Please write neatly using black ink and do not write on the stack of ODH Form No. 274C
Forms.
The ODH Form No. 274C contains new requirements from CDC along with additions from
our medical advisory team and feedback from Take Charge! contractors.
Slide 7 - Background Information Continued
Report follow-up of all abnormal findings until a final breast or cervical diagnosis (cancer
or not cancer) is determined.
Results must be documented on OSDH 274C form within 60 days of receiving the
abnormal results.
It may be necessary to have a signed medical release form from the client to obtain the
follow-up diagnostic and/or treatment information to complete the OSDH 274C form.
Your facility should use their own medical release form.
Slide 8 - Implementation Information
Now it is time to go over some implementation information. Begin using the revised
ODH Form No. 274C immediately.
Please discard all previous version of the ODH Form No. 274C upon receipt of the
revised forms.
Services documented on the old forms will be denied until the revised ODH Form No.
274C has been submitted.
To order additional ODH Form No. 274C, complete the Take Charge! order form and
fax it to 405-271-6315 or email it to CancerPCP@health.ok.gov
Take Charge! Follow up, Diagnostic, and Treatment Training
(ODH Form No. 274C) Training
Slide 9 - Implementation Information
The areas with a watermark of 1, 2, 3 and 4 are used to document the procedures,
results, and recommendations the client received.
Each of the four sections have procedures, results, and recommendations for both
breast and cervical services.
If the procedure, result and recommendation are not found on the current form, refer
to the 274C additional information document found on the Take Charge! website.
There should only be one procedure, one result and one recommendation/timing per
watermark area.
Slide 10 - Implementation Information
Please draw a line through the procedure documentation areas if they will not be used
to document services.
If the client receives more than four breast or cervical procedures, additional forms
must be completed.
Complete the final diagnosis, status of diagnosis, date of diagnosis, and treatment
information on the form that has the final procedure
Slide 11 - Implementation Information
Non-clinical components such as the top of 274C form and watermark areas may be
completed by non-clinicians.
Clinical components such as the final diagnosis, treatment status and etc. must be
completed by the Take Charge! contracted licensed healthcare provider that is
facilitating/guiding diagnostic services and initiation of treatment services.
Every field or box must have an answer.
Do not leave a blank area.
Draw a line through areas that will not be completed.
ODH Form 274C is signed by the Take Charge! contracted licensed healthcare provider
only when the form has been reviewed and completed. This is the licensed healthcare
provider that is guiding the services for the client.
Take Charge! Follow up, Diagnostic, and Treatment Training
(ODH Form No. 274C) Training
Slide 12 - Completing Top of Each Breast Follow-up Information Page
Let’s get started on the details of the ODH Form No. 274C. The written instructions for
completing the 274C is located on the Take Charge! website. The form has been broken
down into sections for ease of this training. Throughout this training you will notice that
we have put in mock information about a fictitious Take Charge! client. Each section of
the ODH Form No. 274C will be reviewed separately.
We will review how to complete the 274C for both breast and cervical follow up
information. We will review the breast information first.
Mark the box in front of the word “breast”.
Write the client’s last name, first name, middle initial and maiden name.
Enter the client’s date of birth. If the client has different name or date of birth from the
Take Charge! Letter, please provide a proof of ID or correct the name on the Take
Charge! Letter.
Write in your facility's four-digit facility code that was given to you when you received
your contract. This is not the facility that you are referring the client to.
Enter the breast screening date, the date of the clinical breast exam. This information
should match 274A.
Please do not leave this area blank.
Slide 13 - Completing the Procedure Information for Breast
Document the first procedure in watermark area 1. Subsequent procedures should be
documented in the order the client received them utilizing watermark areas 2-4. As a
reminder, if the client received more than four procedures use additional 274C forms.
In the watermark area, select the procedure that the client was referred for by placing
a mark in the corresponding box. Please only check one procedure per area. The first
procedure marked on this form must match the procedure you indicated in the Work up
planned section on the 274A form and the referral information as indicated on the ODH
form 1342.
If a procedure is not listed, please write in the missing procedure in the blank area as
indicated on the slide. Use the 274C additional information document for a complete
listing of procedures.
Take Charge! Follow up, Diagnostic, and Treatment Training
(ODH Form No. 274C) Training
Slide 14 - Completing the Procedure Information for Breast
Enter the date the procedure/additional testing was requested.
Enter the name of the facility the client was referred to.
Enter the date that the procedure was performed. Please make sure that the date
performed matches the date shown on back up documentation.
Abnormal findings always require complete work-up within 60 days or less of the
abnormal finding date.
Paid by Take Charge! should be marked “Yes” if the procedure was ordered using an
ODH Form No. 1342.
If the procedure was paid by Oklahoma Cares/Medicaid, mark “Medicaid”. If the
procedure was paid for by the client’s insurance company, mark “Other”.
Slide 15 - Completing the Procedure Information for Breast
Select only one result of the procedure as we can only enter one result in CaST.
Enter the date the results were received by your facility.
Enter the recommendation and timing of next steps for the client.
If a result is not listed on the form, please write in the result in this area. Please use
the 274C Additional Information document for a complete listing of procedures,
results, and recommendations.
Enter the date the client was notified of the results. This is the date that your facility
notified the client of their results.
Slide 16 - Completing Top of Each Cervical Follow-up Information Page
Now we are going to move completing the ODH Form No. 274C for cervical information.
As a reminder, the written instructions for completing the 274C are located on the Take
Charge! website. We are still using the same fictitious Take Charge! client information.
Mark the box in front of the word cervical.
Write the client’s last name, first name, middle initial and maiden name.
Enter the client’s date of birth. If the client has different name or date of birth from the
Take Charge! Follow up, Diagnostic, and Treatment Training
(ODH Form No. 274C) Training
Take Charge! Letter, please provide a proof of ID or correct the name on the Take
Charge! Letter.
Write in your facility's four-digit facility code that was given to you when you received
your contract. This is not the facility that you are referring the client to.
Enter the cervical screening date, the date of the Pap test and/or the HPV test. This
information should match 274A.
Please do not leave this area blank.
Slide 17 - Completing Procedure Information for Cervical
As previously stated, document the first procedure in watermark area 1. Subsequent
procedures should be documented in the order the client received them utilizing
watermark areas 2-4. As a reminder, if the client received more than four
procedures use additional 274C forms.
In the watermark area, select the procedure that the client was referred for by placing
a mark in the corresponding box. Please only check one procedure per area. The first
procedure marked on this form must match the procedure you indicated in the Work Up
Planned section on the 274A form and the referral information as indicated on the ODH
form 1342.
If a procedure is not listed, please write in the missing procedure in the blank area as
indicated on the slide. Use the 274C additional information document for a complete
listing of procedures.
Slide 18 - Completing Procedure Information for Cervical
Enter the date the procedure/additional testing was requested.
Enter the name of the facility the client was referred to.
Enter the date that the procedure was performed. Please make sure that the date
performed matches the date shown on back up documentation.
Abnormal findings always require complete work-up within 60 days or less of the
abnormal finding date.
Paid by Take Charge! should be marked “Yes” if the procedure was ordered using an
ODH Form No. 1342.
Take Charge! Follow up, Diagnostic, and Treatment Training
(ODH Form No. 274C) Training
If the procedure was paid by Oklahoma Cares/Medicaid, mark “Medicaid”. If the
procedure was paid for by the client’s insurance company, mark “Other”.
Slide 19 - Completing Procedure Information for Cervical
Select only one result of the procedure as we can only enter one result in CaST.
Enter the date the results were received by your facility.
Enter the recommendation and timing of next steps for the client.
If a result is not listed on the form, please write in the result in this area. Please use
the 274C Additional Information document for a complete listing of procedures,
results, and recommendations.
Enter the date the client was notified of the results. This is the date that your facility
notified the client of their results.
Slide 20 - Final Components of Page 1 & Page 2
From this point on, we will cover both breast and cervical responses together.
Indicate the final diagnosis of the client by marking either not cancer or cancer.
If the client was diagnosed with cancer, obtain a copy of the surgical pathology
report to submit with the 274C. Mark the box indicating that a copy of the surgical
pathology report is attached.
If a final diagnosis is not listed on the form, please write it in in the area
indicated on the slide. Please use the 274C Additional Information document
for a listing of final diagnosis which may also be used on the 274C.
Indicate the status of the diagnosis, select only one response.
Before you mark refused or lost to follow-up as the status of diagnosis, contact the
Take Charge! Patient navigator. The Take Charge! patient navigator will provide you
with further guidance.
If a status of diagnosis is not listed on the form, please write it in the area
indicated on the slide. Please use the 274C Additional Information document
for a listing of status of diagnosis which may be used on the 274C.
Enter the date of diagnosis.
Take Charge! Follow up, Diagnostic, and Treatment Training
(ODH Form No. 274C) Training
If breast and/or cervical cancer was not diagnosed, draw a line through the
treatment status area and date treatment started.
Enter the date of the client’s next mammogram or Pap test.
Slide 21- Final Components of Page 1 & Page 2
Indicate the date the copy of 274C was sent to your billing office for invoice
preparation.
Indicate the date the original was retained in the client chart/scanned and stored
electronically.
Once the ODH Form No. 274C is complete, the healthcare provider that performed
the screening services, facilitated diagnosis and initiation of treatment services must
review, sign, date and print their name on the form.
If the client has a Medicaid number, enter the woman’s Medicaid number on the
form. If she doesn’t have one, enter N/A.
Slide 22 - Skill Assessment
The final thing to do, is to complete the skill assessment. The skill assessment is located
on the Take Charge! website below the training files. If there are any issues with the
skill assessment, please contact Take Charge! Administrative staff at 405-271-3619.
Slide 23 - Contact Information
This is the contact information for the Take Charge! Program.
The Take Charge! Toll free number is 1-888-669-5934.
The number for the Center for Chronic Disease Prevention and Health Promotion is 405-
271-3619.
You can also email at cancerpcp@health.ok.gov, just please do not email any protected
health/confidential information.
The fax number is 405-271-6315.
There is also a Take Charge! Website which you can find at the address below.
This concludes the audio portion of the training.
