Patient Interview/readmission Chart Review Page 8
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122. NAME OF PROVIDER THAT REFERRED
3. OUT-PATIENT SERVICE
4. DATE OF REFERRAL
5. DATE OF APPOINTMENT
6. DIFFERENCE BETWEEN REFERRAL AND APPOINTMENT DATE
7. APPOINTMENT KEPT
Yes
No
a. NO
i. NO SHOW
1. FOLLOW UP PHONE CALL
2. INFO SENT TO REFERRAL SOURCE
ii. PATIENT/FAMILY CANCELLED
iii. MD/HOSPITAL CANCELLED
iv. RESCHEDULED
v. NO SHOW STATUS SENT TO REFERRING SOURCE
b. YES
i. STATUS (STABLE OR UNSTABLE )
ii. REFERRAL (APPROPRIATE OR INAPPROPRIATE )
iii. PLAN OF CARE ESTABLISHED (YES OR NO)
iv. RETURN APPOINTMENT MADE (YES OR NO)
8. APPT REMINDER CALL MADE TO PATIENT (YES OR NO, IF NO WHY)
9. PRE-APPOINTMENT INFORMATION SENT TO PATIENT (YES OR NO, IF NO WHY)
10. IN YOUR OPINION THAT ARE THE TOP REASONS PATIENT WAS READMITTED TO THE HOSPITAL
a.
b.
c.
11. ADDITIONAL COMMENTS
Summary/Assessment of Readmission Review
Name of CM doing this assessment:___________________________
Date assessment completed:
____________________________
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