CONSENT PROCESS Completed by Date/time Date entered Sent to Saved in (initials) completed into GWTG Iszet MaRISS file ICF signed N/A N/A ICF Copy to patient N/A N/A N/A ICF Copy to chart N/A N/A N/A ICF Original N/A N/A Baseline contact information form N/A N/A Baseline visit NIH Baseline criteria to code RISS Baseline Prehospital fluctuation form 30 day follow up call appointment made at N/A N/A time of consent ICF and MaRISS documentation in N/A N/A N/A McKesson computer discharge instruction tab Other task to be completed:_____________ 30-day appointment date/time: ______________ 30-day appointment documented in DC instructions: YES NO If no, why not? ____________________________________ 24 hours to Date/Time Completed Date/time Date entered Sent to Saved in DAY 3 or DISCHARGE Due by completed into GWTG Iszet MaRISS file (initials) 24-hour visit NIHSS Day 3 or DC NIHSS Day 3 TOAST Day 3 post-hospital fluctuation form Reinforce 30 day appointment call N/A N/A N/A ICF and MaRISS documentation in N/A N/A N/A McKesson computer discharge instruction tab POST- DISCHARGE Date/Time Completed Date/time Date entered Sent to Saved in 30 DAY call Due by completed into GWTG Iszet MaRISS file (initials) 30 day follow up call completed mRS only 90 day follow up call appointment N/A N/A made at time of 30 day call 90-day appointment date/time: ______________ POST- DISCHARGE Date/Time Completed Date/time Date entered Sent to Saved in 90 DAY call Due by completed into GWTG Iszet MaRISS file (initials) 90 day follow up call completed mRS Barthel Index
CONSENT PROCESS Completed by (initials) Date/time completed Date entered into GWTG Sent to Iszet Saved in MaRISS file ICF signed N/A N/A ICF Copy to patient N/A N/A N/A ICF Copy to chart N/A N/A N/A ICF Original N/A N/A Baseline contact information form N/A N/A Baseline visit NIH Baseline criteria to code RISS Baseline Prehospital fluctuation form 30 day follow up call appointment made at time of consent N/A N/A ICF and MaRISS documentation in McKesson computer discharge instruction tab N/A N/A N/A Other task to be completed:_____________ 30-day appointment date/time: ______________ 30-day appointment documented in DC instructions: YES NO If no, why not? ____________________________________ 24 hours to DAY 3 or DISCHARGE Date/Time Due Completed by (initials) Date/time completed Date entered into GWTG Sent to Iszet Saved in MaRISS file 24-hour visit NIHSS Day 3 or DC NIHSS Day 3 TOAST Day 3 post-hospital fluctuation form Reinforce 30 day appointment call N/A N/A N/A ICF and MaRISS documentation in McKesson computer discharge instruction tab N/A N/A N/A POST- DISCHARGE 30 DAY call Date/Time Due Completed by (initials) Date/time completed Date entered into GWTG Sent to Iszet Saved in MaRISS file 30 day follow up call completed mRS only 90 day follow up call appointment made at time of 30 day call N/A N/A 90-day appointment date/time: ______________ POST- DISCHARGE 90 DAY call Date/Time Due Completed by (initials) Date/time completed Date entered into GWTG Sent to Iszet Saved in MaRISS file 90 day follow up call completed mRS Barthel Index
Patient%20Study%20Guide%20Form%20Template.docx