(Sample

Telephone Interaction and Documentation QI Process

Month of Review:

CONFIDENTIAL

Documentation (note "+", "-", or "NA")
Patient's Initials          
Date of call          
Nurse's Initials:          
VITAL DATA
Length of call back time          
Total length of call (minutes)          
Patient's name          
Date of birth          
Primary physician/MD on call          
Telephone number          
Medication allergies          
Patient's weight          
Current medications          
SYMPTOMS & ASSESSMENT
History of current illness          
Duration of symptoms          
Pertinent negatives          
Review of systems          
Past medical history          
DISPOSITION & COMMENTS
Protocol utilized (chief complaint)          
Call managed per protocol          
Caller understanding          
Caller preference          
Disposition          
MD notified with times          
Nursing Assessment          
Hospital patient referred to          
Insurance/Insurance disclaimer          
RN signature          

QA CODE

         
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For any chart with QA code of 4 or 5, copy call record forward to Program Director for secondary review:

1: No disagreements, excellent care 3: Some disagreements, no potential for harm 5: Definite potential for harm
2:No disagreements, adequate care 4: Major disagreements, some potential for harm  
Initials of reviewer:______________    
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