Patient/family Safety Liaison Encounter Form Page 3

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Findings forwarded to Risk Manager_______
Patient Follow up plan
Pt requests anonymity
Pt requests follow up
Telephone: ____________________
Action plan identified by risk manager:
Probing questions:
Do you ever have questions about your care that are not answered?
Are you able to get appointments when you need them?
Is there anything about your care plan that you find inefficient?
Is there anything that should have been completed prior to your appointment/procedure/test/treatment that had not been
done?
Do you have the right information at the right time to make informed decisions about your care?
Do you think the physical environment at this organization is safe?
Were your medical records available at the time of your appointment?
Was everything ready for your appointment?
Were test results (lab, x-ray, etc.) communicated in a timely manner?
Patient Safety Rounds Toolkit

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