Telephone Log Template And Triage Tool

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Telephone Log and Triage Tool
PHONE/CONTACT DATE: _________________ STAFF NAME: __________________________DURATION:__________________
CONTACT TYPE: _____ Family
_____ Community
_____ Provider
NOTES: ___________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Primary Care Provider:
______Lack of Provider ______Problem with Provider
PCP: ______________________________________________________________________Phone: _________________________
Specialist(s): ________________________________________________________________Phone: _________________________
Diagnosis: _________________________________________________________________________________________________
Child’s Age Group: _______0-3 _______3-5 _______5-11 _______11-14 _______14-18 _______18-21 _______Over 21
********************************************************************************************************************************************************
REASON FOR CALL: _____ Denied Coverage: ______Information: ______ Problem with: ____ Other: ___________________
CHP +
Medicaid
Medicaid Waiver
Public Assistance
Part C
Private Insurance
SSI
Other
NEEDS: Other:
None
Basic Needs
Diagnosis Question
Psychosocial/Mental Health
Growth & Development
Health/Medical
Family Support Advocay
Social Group/Peer Support
Faith Based Community
Respite
REFERRALS GIVEN: Other:
None
CCB
Community Education
Community Family Support
Community Financial
Community Health/Insurance
Community Health/Public Systems
Community Providers
County Nursing Service
D & E Coordinator
Health Department
Home Health Care
Visiting Nurse
Women’s Health
TBI
Other:
Community Provider NAME (Program or Individual): _______________________________________________________________________________
Comments:________________________________________________________________________________________________________________
:
TRIAGE OUTCOME
____ No F/U Needed ____ Follow-up Phone Call ____ Mail Materials ____ Other: ________________________________
Referral to: _____ Nursing _____SW _____ Nutrition _____ OT/PT
_____ Family
____ Audiology ____ Vision ____ SLP
_____ Need HCP Care Coordination: _____ Level 2
_____ Level 2 and HCP Clinic
____ Level 3
CONTACT INFORMATION
(Optional- only if F/U is needed)
:
Child’s Name: _________________________________________DOB:___________________ Age: ___________________
Family Name: _________________________________________________________________________________________
Address: _____________________________________________________________________________________________
ZIP: ________________ Phone: _____________________ E-Mail: ______________________________________________
Comments: __________________________________________________________________________________________________
___________________________________________________________________________________________________________
HCP Clinics Only: Estimated Family Annual Income ____________________ or Monthly Income ___________________________
HCP Staff Name: __________________________________ Date Entered in HCP CHIRP Phone Log and Shredded: _____________
5-06 HCP Telephone Log and Triage Tool

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