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Surveys
2015
January
C
Call Tracker
Call Tracker
Terra Greene MSN, RN
UM Clinical Consultant, Readmissions Nurse
Maryland Physicians Care
0%
Exit Survey
Core member 4, 5 6?
Core member 4
Core member 5
Core member 6
Call conducted with..
Member
Parent/Guardian
Foster Parent
Spouse/Significant other
Adult son/Adult daughter
Caregiver
Other
It appears as if you/your child may have had a recent hospital admission. Is that correct? (if "no", discontinue questionaire)
Yes
No
When were you/your child discharged?
<10 days ago
10 days to a month ago
>a month ago
Tell me about you/your child's recent hospitalization...(
(Nurse to provide education related to diagnosis, written education-KRAMES-related to morbidity)
Did Nurse provide education?
Yes
No
Was this a planned/elective admission to the hospital?
Yes
No
If hospitalization was not elective, what barriers contributed to you/your child's hospital admission?
Member cannot identify contributig factors
End stage disease/health status decline
Doctor/clinic did not have appointments available
Lack of transportation
Could not afford office co-pay
Could not afford medications
Could not afford ancillary care (home care, outpatient therapy, etc;)
Could not afford Disposable Medical Equipment
Could not afford dietary requirements
Forgot to take medications
Poor understanding of disease process/plan of care
Non compliant with plan of care
Other
Do you have a personal discharge record/instructions from the hospital?
Yes, I have a personal discharge record I assisted with developing
Yes, I have discharge instructions from the hospital
No
What, if any, new issues/cahnges in condition have occurred since your most recent discharge from the hospital?
ER Visit
Change in medication
Problem worsened
New Problem
Did a doctor discuss with you ways of staying out of the hospital in the future?
Yes
No
Created by T. Greene MSN, RN
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