(Sample) Telephone Interaction and Documentation QI Process |
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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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