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Chief Complaint
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Date of Discharge:
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Discharging Facility:
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Primary Reason for Admission:
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Diagnosis at Discharge:
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Date of Contact:
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Mode Of Contact
• • •
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Contacted
• • •
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Brief Summary
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Visit Date
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Visit Mode (In person or Video)
• • •
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Provider
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Complexity
• • •
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Rationale For Complexity [Insert reasoning: # of problems, complexity of data reviewed, high-risk decisions, etc.]
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Discharge Medications Reviewed
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Home Medications Reviewed:
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Changes Made:
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New Yes / No
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