Postdischarge Followup Phone Call Documentation Form

Re-Engineered Discharge (RED) Toolkit

This form available for download in two formats:


Patient name:

Caregiver(s) name(s):

Relationship to patient:

Notes:

Discharge date:

Principal discharge diagnosis:

Interpreter needed? Y N Language/Dialect:


Prior to phone call:

Review:

  • Health history.
  • Medicine lists for consistency.
  • Medicine list for appropriate dosing, drug-drug and drug-food interactions, and major side effects.
  • Contact sheet.
  • DE notes.
  • Discharge summary and AHCP.

Call Completed: Y N

With whom (patient, caregiver, both): _______________________________________________
Number of hours between discharge and phone call: ___________________________________

Consultations (if any) made prior to phone call:

___  None
___ Called MD
___ Called DE
___ Called outpatient pharmacy
___ Other: __________________________________________________________________

If any consultations, note to whom you spoke, regarding what, and with what outcome:

_______________________________________________________________________

_______________________________________________________________________

Phone Call Attempts

Patient/Proxy

Phone Call #1: Date & Time:________ Reached: Yes/No

If No (circle one): answering machine/no answer/not home/declined/busy/rescheduled/other:

Phone Call #2: Date & Time:________ Reached: Yes/No

If No (circle one): answering machine/no answer/not home/declined/busy/rescheduled/other:

Phone Call #3: Date & Time:________ Reached: Yes/No

If No (circle one): answering machine/no answer/not home/declined/busy/rescheduled/other:

Phone Call #4: Date & Time:________ Reached: Yes/No

Alternate Contact 1

Phone Call #1: Date & Time:________ Reached: Yes/No

If No (circle one): answering machine/no answer/not home/declined/busy/rescheduled/other:

Phone Call #2: Date & Time:________ Reached: Yes/No

If No (circle one): answering machine/no answer/not home/declined/busy/rescheduled/other:

Phone Call #3: Date & Time:________ Reached: Yes/No

If No (circle one): answering machine/no answer/not home/declined/busy/rescheduled/other:

Phone Call #4: Date & Time:________ Reached: Yes/No

Alternate Contact 2

Phone Call #1: Date & Time:________ Reached: Yes/No

If No (circle one): answering machine/no answer/not home/declined/busy/rescheduled/other:

Phone Call #2: Date & Time:________ Reached: Yes/No

If No (circle one): answering machine/no answer/not home/declined/busy/rescheduled/other:

Phone Call #3: Date & Time:________ Reached: Yes/No

If No (circle one): answering machine/no answer/not home/declined/busy/rescheduled/other:

Phone Call #4: Date & Time:________ Reached: Yes/No

A. Diagnosis and Health Status

  • Ask patient about his or her diagnosis and comorbidities:

    ___ Patient confirmed understanding
    ___ Further instruction was needed

  • If primary condition has worsened: What, if any, actions had the patient taken?
    ___ Returned to see his/her clinician (name):_____________________________________
    ___ Called/contacted his/her clinician (name):____________________________________
    ___ Gone to the ER/urgent care (specify):_______________________________________
    ___ Gone to another hospital/MD (name):_______________________________________
    ___ Spoken with visiting nurse (name):_________________________________________
    ___ Other:_______________________________________________________________
    ___ What, if any, recommendations, teaching, or interventions did you provide?


  • If new problem since discharge:
    • Had the patient:

         ___ Contacted or seen clinician? (name):________________________________________
         ___ Gone to the ER/urgent care? (specify):______________________________________
         ___ Gone to another hospital/MD? (name):______________________________________
         ___ Spoken with visiting nurse? (name):________________________________________
         ___ Other?:_______________________________________________________________

  • Following the conversation about the current state of the patient's medical status:
    • What recommendations did you make?

         ___ Advised to call clinician (name):___________________________________________
         ___ Advised to go to the ED
         ___ Advised to call DE (name):_______________________________________________
         ___ Advised to call specialist physician (name):__________________________________
         ___ Other:_______________________________________________________________

    • What followup actions did you take?
         ___ Called clinician and called patient/caregiver back
         ___ Called DE and called patient/caregiver back
         Other: ___________________________

B. Medicines

  • Document any medicines patient is taking that are NOT on AHCP and discharge summary: ___________________________________________________________________________
  • Document problems with medicines that are on the AHCP and discharge summary (e.g., has not obtained, is not taking correctly, has concerns, including side effects):

    Medicine 1:_________________________________________________________________

    P roblem:___________________________________________________________________
    ___ Intentional nonadherence
    ___ Inadvertent nonadherence
    ___ System/provider error
    • What recommendation did you make to the patient/caregiver?
      ___ No change needed in discharge plan as it relates to the drug therapy
      ___ Educated patient/caregiver on proper administration, what to do about side effects, etc.
      ___ Advised to call PCP
      ___ Advised to go to the ED
      ___ Advised to call DE
      ___ Advised to call specialist physician
      ___ Other:_______________________________________________________________
    • What followup action did you take?
      ___ Called hospital physician and called patient/caregiver back
      ___ Called DE and called patient/caregiver back
      ___ Called outpatient pharmacy and called patient/caregiver back
      ___ Other:_______________________________________________________________

    Medicine 2:_________________________________________________________________

    Problem:___________________________________________________________________
    ___ Intentional nonadherence
    ___ Inadvertent nonadherence
    ___ System/provider error
    • What recommendation did you make to the patient/caregiver?

      ___ No change needed in discharge plan as it relates to the drug therapy
      ___ Educated patient/caregiver on proper administration, what to do about side effects, etc.
      ___ Advised to call PCP
      ___ Advised to go to the ED
      ___ Advised to call DE
      ___ Advised to call specialist physician
      ___ Other:_______________________________________________________________

    • What followup action did you take?
      ___ Called hospital physician and called patient/caregiver back
      ___ Called DE and called patient/caregiver back
      ___ Called outpatient pharmacy and called patient/caregiver back
      ___ Other:_______________________________________________________________
  • Medicine 3:_________________________________________________________________

    Problem:___________________________________________________________________
    ___ Intentional nonadherence
    ___ Inadvertent nonadherence
    ___ System/provider error
    • What recommendation did you make to the patient/caregiver?

      ___ No change needed in discharge plan as it relates to the drug therapy
      ___ Educated patient/caregiver on proper administration, what to do about side effects, etc.
      ___ Advised to call PCP
      ___ Advised to go to the ED
      ___ Advised to call DE
      ___ Advised to call specialist physician
      ___ Other:_______________________________________________________________

    • What followup action did you take?
      ___ Called hospital physician and called patient/caregiver back
      ___ Called DE and called patient/caregiver back
      ___ Called outpatient pharmacy and called patient/caregiver back
      ___ Other:_______________________________________________________________

C. Clarification of Appointments

Potential barriers to attendance identified: ___ Y ___ N

List:__________________________________________________________________________

Potential solutions/resources identified: ___ Y  ___ N

List:__________________________________________________________________________

Alternative plan made: ___ Y ___ N Details:____________________________________________

Clinician/DE informed: ___ Y ___ N Details:____________________________________________

D. Coordination of Postdischarge Home Services (if applicable)

Document any postdischarge services that need to be checked on and who will be doing that (caller/patient/caregiver).

E. Problems

Did patient/caregiver know what constituted an emergency and what to do if a nonemergent problem arose?

___ Yes       ___ No
If no, document source of confusion:

F. Additional Notes

 

G. Time

Time for reviewing information prior to phone call:_____________________________________

Time for missed calls/attempts:_____________________________________________________
 

Time for initial phone call:_________________________________________________________
 

Time for talking to other health care providers:
 

Time for followup/subsequent phone calls to patient:____________________________________
 

Time for speaking with family or caregivers:__________________________________________
 

Total time spent:________________________________________________________________

Caller's Signature:_______________________________________________________________

Page last reviewed March 2013
Internet Citation: Postdischarge Followup Phone Call Documentation Form: Re-Engineered Discharge (RED) Toolkit. March 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/red/toolkit/postdischarge-doc.html