Patient Interview/readmission Chart Review Page 4
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12Who to contact (and how) if you were experiencing worsening of your disease Yes
No
Not sure
Were you asked about your understanding of the d/c instructions
Yes
No
Not sure
Were the discharge instructions easy for you to understand
Yes
No
Not sure
Do you still have a copy of your discharge instructions
Yes
No
Not sure
At the time of d/c, did someone talk with you about which medication to take when you left, and which
ones to discontinue?
Yes
No
Not sure
Did you take your medications as they were prescribed ?
Yes
No
Not sure
What difficulties did you experience with taking your medications?
Did you have a follow up appointment with your doctor?
Yes
No
Not sure
Were you able to get to your follow up appointment?
Yes
No
Review sent to Outpatient Facility
Yes
No
Name and number:
Home Health Chart Review Form
Date
Reviewer initials: __________ Case mgr initials:
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