Patient Interview/readmission Chart Review Page 11
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12Not adequately planning for follow-up of care
Yes
Potentially preventable issues-SYSTEM ISSUES:
Inadequate post discharge follow up
Inadequate referral made such as palliative care, hospice, HH
Yes
Lack of timely HH visit or phone follow-up
Yes
Lack of timely follow-up appointments with MD
Yes
Lack of follow up MD appointment
Yes
Inadequate coordination and or communication across Outpatient Services (wound clinic, home
health CHF etc)
Yes
Inadequate medication management (med review and med rec)
Wrong or contra-indicated medication prescribed at time of discharge
Yes
Medication discrepancies resulted because of lack of adequate coordination between inpatient-
outpatient
Yes
Patient did not leave the hospital with accurate printed med list
Yes
Med list in discharge summary did not match what the patient takes at home
Yes
Lack of timely or accurate exchange of health care information
PCP, Home Health, Nurse Navigator, Outpatient clinics or other providers did not have
information they needed (information was not transferred or received adequately after d/c to
accountable providers) Yes
Explanation for systems issues identified in previous question and WHY readmission occurred:
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