Patient Interview/readmission Chart Review Page 6

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Home Health Chart Review Form
Date
Reviewer
Name__________________________________________
Patient name____________________________________________
First hospital DX__________________________________________
Readmission DX__________________________________________
Discharge Date from first admission__________________________
Referral date to HH________________________________________
Admission date to HH______________________________________
Was admission visit completed within 1 day of discharge form hospital
Yes No
If no, why not
Was second nursing visit completed on day 3 post hospital
yes No
If no, why not
SN visits performed 3 times a week for first two weeks then 2 times per week
Yes No
If no, why not
Was Telehealth set up on day 2 post hospital
Yes No
If no, why not
Phone calls between visits for first two weeks if no telehealth
Yes No
If no, why not
Was Chronic Disease Mgmt implemented
Yes No
Did patient upon discharge from hospital have an appointment with MD within 7 days of discharge yes
no
What date______

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Parent category: Medical