Root Cause Analysis Template: Chart Review Of Unplanned Transfers
ADVERTISEMENT
1
2Root Cause Analysis: Chart Review of Unplanned Transfers
Demographic Information
AllScripts #: _____________________________
Date of Admission to Hospital:_______________
Time of Transfer: ___________
Date of Last Visit by Agency Clinician:________
Clinician Name: ______________________________
Reason for Transfer Per Record:____________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Reason for Transfer Per Conversation with Family Member: ______________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Within 72 hours prior to transfer, were any of the following signs or symptoms or conditions present?
□
□
Fever: _______________________________
Signs & Symptoms of UTI: __________________
□
□
Change in Mental Status: _______________
Signs & Symptoms of SOB: _________________
□
□
Decreased Oral Intake: _________________
Change in Vital Signs: ______________________
□
□
Change in Medications: _________________
One or More Falls: _________________________
□
Increased Pain/Pain Medication Requirement: _______________________________________________
□
Family Mention of Change in Condition: ___________________________________________________
Action Taken Prior to Transfer:
□
□
Was the patient's physician or mid-level provider contacted prior to transfer?
Yes
No
□
□
Was HHHC's Hospice physician or mid-level provider contacted prior to the transfer?
Yes
No
□
□
Was the transfer due to lack of a home visit by a clinician?
Yes
No
□
□
Was the transfer due to lack of caregiver support in the home?
Yes
No
□
□
Was the transfer due to a lack of community resources in the home?
Yes
No
□
□
Was the patient on Telehealth with our agency?
Yes
No
□
□
□
Could this Transfer Have Been Avoided?
Yes
No
Possibly
Explain: _______________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business