Patient Interview/readmission Chart Review Page 10
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12Psycho-social issues
Yes
Potentially preventable issues-SYSTEM ISSUES: Based on the interviews conducted and chart
review, identifying systems issues or actions that may have contributed to this readmission
(chose all that apply)
Inadequate assessment by the care planning team (MD, CM/SW, RN, PT/OT) of
patient or caregiver needs while in the hospital
Not adequately assessing functional status prior to discharge
Yes
Not adequately assessing psychological or social needs prior to discharge
Yes
Not adequately assessing patient needs in the home
Yes
Not adequately assessing patient needs post discharge
Yes
Patient discharged too soon, e.g. failure to diagnose prior to discharge or not recognizing
worsening of clinical status in hospital
Yes
Inadequate care planning and education
Not adequately assessing patient understanding of who to call or when at home
Yes
Not adequately assessing caregiver understanding of who to call or when at home
Yes
Not adequately assessing patient understanding of care plan or self-management instructions
prior to
leaving the hospital
Yes
Not adequately assessing care provider of care plan instructions prior to leaving the hospital
Yes
Not adequately assessing patient understanding of warning s/s for calling provider
Yes
Not adequately assessing care provider understanding of warning s/y for calling provider
Yes
Not adequately assessing patient inclusion in discussion of d/c instructions
Yes
Not adequately assessing caregiver inclusion in discussion of d/c instructions
Yes
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