Tcm Documentation And Flow Sheet
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TCM Documentation and Flow Sheet
TCM Requirements for
Post-Discharge Contact Deadlines:
2 days post discharge date ____/____/______
Note: To ensure all required documentation to support TCM services is completed, and so
7 days post discharge date ____/____/______
that none of these 4 pages get lost, reproduce this form on the front and back of 11x17
14 days post discharge date ____/____/______
paper and fold it in half to 8 1/2 x 11 booklet size.
Patient Name: ____________________________________________________________________________________
Patient DOB: ____/_____/_______ Discharge Date/Day:____/_____/_______
M Tu W Th F Sa Su
Patient’s Physician: __________________________________________________________________________________
Reason for Admission: _______________________________________________________________________________
Patient Caregiver Name:______________________________ Relationship: __________________
Contact Information:
Preferred method of contact: phone cell text e-mail
Phone:
Home: (_______)______________________
Cell:
(_______)______________________
Work:
(_______)______________________
E-mail address (if applicable): _____________________________________________________________
Is Home Health Involved?
No
Yes — if yes, please include home health contact information:
Contact person: ___________________________________ Company name:_________________________________________
Phone: (_______)_________________________________
Fax: (_______)__________________________________________
E-mail (if applicable): _______________________________________________________________________________________
Discharge Information:
Diagnosis(es) at discharge: _____________________________________________________________________________
Discharging physician
: ___________________________________________________________________
(name and phone #)
Discharge Information Obtained:
Discharge summary:
Date rec’d: _____/______/________
Copies of discharge instructions:
Date rec’d: _____/______/________
Most recent diagnostic test results:
Test name: _________________________________ Date rec’d: _____/______/________
Test name: _________________________________ Date rec’d: _____/______/________
Test name: _________________________________ Date rec’d: _____/______/________
Patient Current Location:
Home Family member home Non-family member home Assisted living facility Rest home
Other: _____________________________________________________________________________________________
Initial Communication
First 2 attempts must be within 2 business days of discharge (see discharge date at top of page).
Post-Discharge:
Continue attempting to reach the patient, even if the attempts during the first 2 days are unsuccessful.
1st attempt:
Date: ___/___/____ Time: ____:_____
Method:
call fax e-mail mail
Initial: _________
□ am □ pm
call fax e-mail mail
2nd attempt:
Date: ___/___/____ Time: ____:_____
Method:
Initial: _________
□ am □ pm
Add'l attempts: Date: ___/___/____ Time: ____:_____
Method:
call fax e-mail mail
Initial: _________
□ am □ pm
Date: ___/___/____ Time: ____:_____
Method:
call fax e-mail mail
Initial: _________
□ am □ pm
Date: ___/___/____ Time: ____:_____
Method:
call fax e-mail mail
Initial: _________
□ am □ pm
Date: ___/___/____ Time: ____:_____
Method:
call fax e-mail mail
Initial: _________
□ am □ pm
** Once you reach patient or caregiver go to page 2.
Compliments of Family Practice Coding Advisor, published by Coding Leader. Authorization to reprint by Coding Leader for individual use only.
phone: 800-767-1181; fax: 800-767-9706; e-mail: info@codingleader.com; web:
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