Patient Interview/readmission Chart Review Page 5
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12Patient name____________________________________________
Transfer date and reason __________________________________________
HH SOC date and reason______________________________________
Education focus: ______________________________________________
Was admission visit completed within 1 day of discharge from hospital
yes no
If no , how many days from dc and why
SN visits – were visits front loaded if high risk for readmit
yes no
If no why
Was Telehealth set up on day 2 post hospital , (if applicable)
yes no
If no why
Phone calls between visits for first two weeks if no telehealth , (if applicable)
yes no
If no why
Did patient upon discharge from hospital have an appointment with MD within 7 days of discharge yes no
what date
Did patient keep appointment with MD
yes no
if no why
Did the patient have all meds on admit to HH
yes no
If not why
Was the patient compliant with meds
yes no
If not, explain
Any physician Order discrepancies found?
Yes no
If yes, explain
Total number of visits:
Number of visits by Case Manager: SN ______ PT_______ OT
________
Number of different clinicians:
SN
LPN
OT
PT
LPTA
# of Weekend visits completed by clinician other than Case Mgr __________
# of Phone visits completed by clinician other than Case Mgr _____________
During the time between admission to home health and readmission to hospital were there any
issues and any issues and how were the issues addressed? Explain:
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