Contact Sheet (1)

Re-Engineered Discharge (RED) Toolkit

This contact sheet available for download in two formats:


If possible, pull information from patient's medical record. Confirm correct information with patient. Identify the best time of day or days to reach the patient and other contacts.

Patient Name: _________________________________________________________

OK to send letter (Y / N)

Address:
Street ___________________________________________  Apt #________________

City, State _______________________________  ZIP Code _____

Email address: _________________________________________

Preferred spoken language: _____________________________________________

Interpreter needed? (Y/N) ______

Preferred phone number: __ home __ cell phone __ work

Home Phone: (      )_____________________       OK to leave message? (Y/N)____

Best time to call: _______________________

Cell Phone: (      )_______________________       OK to leave message? (Y/N)____

Best time to call: _______________________

Work Phone: (      )______________________       OK to leave message? (Y/N)____

Best time to call: _______________________

Name of Contact 1: _____________________________________________________

Relationship: __________________________________________________________
Caregiver? (Y/N) __
Proxy? (Y/N) __
Designated to receive followup phone call? (Y/N) __

Notes: _______________________________________________________________

_____________________________________________________________________

Preferred spoken language: _____________________________________________

Interpreter needed? (Y/N) ______

Preferred phone number: __ home __ cell phone __ work

Home Phone: (      )_____________________       OK to leave message? (Y/N)____

Best time to call: _______________________

Cell Phone: (      )_______________________       OK to leave message? (Y/N)____

Best time to call: _______________________

Work Phone: (      )______________________       OK to leave message? (Y/N)____

Best time to call: _______________________

Name of Contact2: _____________________________________________________

Relationship: __________________________________________________________
Caregiver? (Y/N) __
Proxy? (Y/N) __
Designated to receive followup phone call? (Y/N) __

Notes: _______________________________________________________________

_____________________________________________________________________

Preferred spoken language: _____________________________________________

Interpreter needed? (Y/N) ______

Preferred phone number: __ home __ cell phone __ work

Home Phone: (      )_____________________       OK to leave message? (Y/N)____

Best time to call: _______________________

Cell Phone: (      )_______________________       OK to leave message? (Y/N)____

Best time to call: _______________________

Work Phone: (      )______________________       OK to leave message? (Y/N)____

Best time to call: _______________________

Page last reviewed March 2013
Internet Citation: Contact Sheet (1): Re-Engineered Discharge (RED) Toolkit. March 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/red/toolkit/contactsheet.html