Hospital Discharge Follow-up Documentation-Sample Template

This is a sample template for documenting outreach following hospital discharge.

Use this information to inform the development of a template in your electronic medical record.

Patient Name ___________________   DOB: ______________   MRN: __________________

Phone Call Attempt #1 

Date & Time

☐ Did Not Reach         ☐ Left Message                         ☐ Unable to leave message

☐ Reached                    Spoke With ☐ Patient              ☐ Family/Friend/Caregiver   

Documented by:  ______________________________

Phone Call Attempt #2  

Date & Time

☐ Did Not Reach         ☐ Left Message                         ☐ Unable to leave message

☐ Reached                    Spoke With ☐ Patient              ☐ Family/Friend/Caregiver  

Documented by:  ______________________________

Phone Call Attempt #3 

Date & Time

☐ Did Not Reach         ☐ Left Message                         ☐ Unable to leave message

☐ Reached                    Spoke With ☐ Patient              ☐ Family/Friend/Caregiver   

Documented by:  ______________________________

  ☐ Unable to Reach Letter sent after third phone call attempt

Discharge

Discharge Diagnosis: ______________________

☐  Reviewed diagnosis and current status with patient or family/friend/caregiver

☐  Required further instruction/education

☐ Teach back completed

☐  Understanding confirmed

Condition worsening or patient appears unstable?    ☐  Yes              ☐ No

If Yes, actions taken:

☐ Scheduled follow up appointment with PCP

☐ Scheduled follow up appointment with specialist or other

☐  Notified provider (Name of provider) 

☐ Instructed to go to ER         ☐ Instructed to go to Urgent Care

☐ Contacted home care nurse/agency (name)

☐ Instructions/Education provided (Describe) ____________________________

☐ Other (describe) _______________________________

Medications

☐ Medications reviewed with patient/family/caregiver

☐ medication updated in EHR

☐ New Rx’s filled and picked up?       ☐ N/A (no new Rx’s)

New Rx’s: (list each new medication & dose)

Patient taking medications as prescribed?   ☐ Yes    ☐ No

If not taking medications as prescribed, note specific medicine(s) and reason for each:

Medicine #1: (insert name of medicine)

Reason not taking as Rx’d:  ☐ has not filled  ☐ side effects      ☐ knowledge deficit

Medicine #2: (insert name of medicine)

Reason not taking as Rx’d:  ☐ has not filled  ☐ side effects      ☐ knowledge deficit

Medicine #3: (insert name of medicine)

Reason not taking as Rx’d:  ☐ has not filled  ☐ side effects      ☐ knowledge deficit

Follow Up for medication concerns:

☐ Notified provider    ☐ Obtained clarification & called patient back

☐ Education & Teach back with patient/family/caregiver

☐ Other ____________________________________

Hospital Follow Up Plan

Follow up Appointment with PCP:

☐ Has f/u appointment              ☐ Scheduled f/u appointment                ☐ Other: __________

Barriers to attending appointment:

☐ No barriers                 ☐ Barriers identified

Describe barriers & plan to address: ____________________________________________

Follow up Appointment with Specialist:

☐ Has f/u appointment              ☐ Scheduled f/u appointment                ☐ Other: __________

Barriers to attending appointment:

☐ No barriers                 ☐ Barriers identified

Describe barriers & plan to address: ____________________________________________

Diagnostic Testing:

Patient has f/u diagnostic testing needs:              ☐ No                  ☐ Yes

If yes, describe (test and date): ________________________________________

Notified physician?        ☐ No                 ☐ Yes

Care Coordination

Home Care ordered at discharge?           ☐ No                  ☐ Yes, Agency: _________________

Home Care started, or contact made?    ☐ No                  ☐ Yes

If no, action taken: ___________________________

DME ordered at discharge?         ☐ No                  ☐ Yes, what type: _________________

DME obtained or arranged?        ☐ No                  ☐ Yes

If no, action taken: ___________________________

Other Coordination Needs? Describe ______________________________________

Action taken: _________________________________________________________

Education: Worsening Condition

☐ Reviewed signs/symptoms of worsening condition

☐ Patient/family/caregiver able to teach back signs/symptoms of worsening condition

☐ Patient/family/caregiver able to teach back what to do in event of worsening condition

☐ Patient/family/caregiver understand what an emergency is

☐ Patient/family/caregiver understand what a non-emergent situation is and where to seek care for this

Care Manager Plan

Notes:

Follow up Action Items:

Next follow up call