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Patient Name:
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DOB:
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Discharge / Contact Dates
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Discharge Facility:
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Initial Contact Date:
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Discharge Date:
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Second contact date:
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Discharge Diagnosis:
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Third contact date: (optional)
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Phone Assessment
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Concerns Since Discharge
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• • •
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Comments:
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Review of Discharge Instructions
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Patient understands discharge instructions:
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Patient's Concerns:
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Any labs/tests done since leaving the hospital?
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If Yes, what/where:
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Home health ordered with discharge?
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DME ordered with discharge?
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Medication Review
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Medication review performed:
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New meds started since discharge:
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Reason NOT taking meds as prescribed:
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Comments:
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Education
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• • •
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TOC Visit Date
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TOC appointment date:
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