Appendix: Readmission Review Form
Patient Interview/Readmission Chart Review
Previous Hospital Admission Date___________________________ Account Number________________
Previous Hospital D/C Date:
Previous Hospital Discharge Diagnosis:
Previous LACE Score:__________________________ Current LACE Score:_____________________
Current Hospital Readmission Date:____________________ Time:___________________
Number of days between the previous discharge and readmission date:
Current Hospital Readmission Diagnosis
Medication Side Effect
Patient Chart Review Form:
Did the patient have a scheduled physician follow-up visit after initial admission?
Was the physician follow up visit kept after initial admission?
Number of days between initial hospitalization and follow-up physician visit
Did patient have Outpatient Community services post discharge?
Community Services: Home Health/Hospice, Outpatient Clinics, Dialysis Center
Case manager do 7-day follow-up phone call after initial hospitalization?
# of days between initial discharge and follow-up phone call
(Call MD office and speak to Nurse Navigator if applicable)