11. Was the patient referred to a at the time of hospital discharge? Yes No Unknown If yes, did the patient accept? Yes No If yes, had the coach seen patient prior to hospital readmission? Yes No Unknown 12. Was the home care nursing transfer form on the Yes No If yes, was it legible, complete and correct? Yes No Comments: 13. Was Medication Reconciliation completed at SOC? Yes No If yes, were discrepancies found? Yes No If yes, were actions to reconcile defined? Yes No Explain actions needed: 14. Does documentation exist for appropriate patient/caregiver education prior to hospital Yes No readmission? 15. Does documentation exist for appropriate Agency patient/caregiver of Yes No “understanding” education prior to hospital readmission? 16. Was hospital readmission related to problems observed at SOC preceding hospital Yes No readmission? 17. Was hospital readmission caused by a new problem that occurred during the episode Yes No of care? If yes, describe: 18. Was hospital readmission avoidable you do anything differently)? Yes No potentially If yes, explain:
11. Was the patient referred to a at the time of hospital discharge? Yes No Unknown If yes, did the patient accept? Yes No If yes, had the coach seen patient prior to hospital readmission? Yes No Unknown 12. Was the home care nursing transfer form on the Yes No If yes, was it legible, complete and correct? Yes No Comments: 13. Was Medication Reconciliation completed at SOC? Yes No If yes, were discrepancies found? Yes No If yes, were actions to reconcile defined? Yes No Explain actions needed: 14. Does documentation exist for appropriate patient/caregiver education prior to hospital readmission? Yes No 15. Does documentation exist for appropriate Agency patient/caregiver “understanding” of education prior to hospital readmission? Yes No 16. Was hospital readmission related to problems observed at SOC preceding hospital readmission? Yes No 17. Was hospital readmission caused by a new problem that occurred during the episode of care? Yes No If yes, describe: 18. Was hospital readmission potentially avoidable you do anything differently)? Yes No If yes, explain:
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