Patient Interview/readmission Chart Review
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12Appendix: Readmission Review Form
Patient Interview/Readmission Chart Review
Patient Name:
Previous Hospital Admission Date___________________________ Account Number________________
Previous Hospital D/C Date:
D/C MD:____________________________________
Previous Hospital Discharge Diagnosis:
CHF
DM
MI
PNA
COPD
Stroke
Other:
Previous LACE Score:__________________________ Current LACE Score:_____________________
Current Hospital Readmission Date:____________________ Time:___________________
Number of days between the previous discharge and readmission date:
1-7
8-14
15-30
Current Hospital Readmission Diagnosis
Fall
Renal Disease
PNA
Medication Side Effect
Fluid overload
Stroke
CHF
COPD
Scheduled procedure
SOB
DM
Other:
Hospital Review:
Patient Chart Review Form:
Did the patient have a scheduled physician follow-up visit after initial admission?
Yes
No
Was the physician follow up visit kept after initial admission?
Yes
No
Number of days between initial hospitalization and follow-up physician visit
______________
Did patient have Outpatient Community services post discharge?
Yes
No
Community Services: Home Health/Hospice, Outpatient Clinics, Dialysis Center
Case manager do 7-day follow-up phone call after initial hospitalization?
Yes
No
# of days between initial discharge and follow-up phone call
_____________
Provider Interview:
(Call MD office and speak to Nurse Navigator if applicable)
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Parent category: Medical