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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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Education Provided:
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Referrals Made: [Specialists, Home Health, PT, etc.]
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Services Arranged: [Transportation, social work, etc.]
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Follow-Up Scheduled: ☐ Yes – Date: [MM/DD]
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Additional Instructions: [Enter any SDOH, risk factors, etc.]
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Assessment & Plan [Summarize diagnoses, instructions, orders, follow-up timing.]
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