Form #2 Medical Records Review Tool (Test Strategies)

Medical Records Review (Test Strategies)

Hospital Name:
Reviewer Name:
Case #:
Date of Review:
Description of Strategy/Quality Improvement Being Tested (during QI cycles):

Purpose:	The purpose of the records review is to understand from the documentation in the medical record the context around the first hospitalization and the readmission, specifically as relates to patient background, circumstances and events surrounding both admissions, and transition planning.
Sample Size:	10-20 reviews – until themes converge and very little new information is being learned.
Selection Criteria:	Adults with primary insurance Medicaid who have had a readmission within 30 days of a previous admission. Patient is still in hospital or 7 or fewer days since discharge.
Time:	20 minutes maximum.

I. General
Age
Gender	Male Female
Marital status	Married/partnered Widowed Separated Divorced Single Unknown
Are patient Hispanic or Latino/Latina?	Yes No
What is patient’s race?  Please select one or more.	American Indian or Alaska Native Asian Native Hawaiian or other Pacific Islander Black or African American White Unknown
Patient’s primary language spoken at home	_____________________ Unknown
Housing status	Own Rent Live in someone else’s home Shelter Other _______________________ Unknown
Payer	Medicaid Medicaid Managed Care Organization or Health Maintenance Medicaid and Medicare Other – NOT ELIGIBLE
Number of hospitalizations (observation or inpatient) in past 12 months
Number of emergency department visits in past 12 months
Note any documentation of the patient’s social supports, language/ cultural/ economic factors that may affect his/her ability to transition from the hospital
Note any documentation of the patient’s functional status (ability to attend to activities of daily living (ADLs) and instrumental ADL
Is a primary care provider (PCP) noted in the chart?	Yes No
If yes, what is the setting or location of the PCP?	Community health center VA clinic Hospital-based clinic Other _______________________________ Unknown Name of clinic (if known) ______________________________________
II. First Admission
Date of admission
Date of discharge
Length of stay
Admitting chief complaint
Admitting primary diagnosis
Discharge diagnoses (primary and secondary)
Evidence of cognitive dysfunction (delirium or dementia)	Yes _________________________________ No Not addressed
Evidence of mental health issues	Yes _________________________________ No Not addressed
Evidence of substance abuse issues	Yes _________________________________ No Not addressed
Evidence of other chronic diseases	Yes _________________________________ _____________________________________ No
Were any new medications prescribed during hospitalization that must be continued post-discharge?	Yes _________________________________ No
Evidence that a medication list (or other medication instruction) was provided to the patient	Yes No
Evidence that self-management guides, instruction, or other material was provided to the patient	Yes No
Was a follow-up (post-discharge) appointment with the PCP made?	Yes No Unknown
Are any specialist providers noted? If yes, what specialties?	Yes _______________________________ No
Was a follow-up (post-discharge) appointment made with any specialist(s)? If yes, which ones?	Yes No Unknown
What setting was the patient discharged to?	Own home Home with home health Relative/caretaker home Rehabilitation facility Nursing home/long-term care facility Home with hospice Shelter Other _______________________________ Unknown
III. Readmission
Date of admission
Source of admission	Own home Home with home health Relative/caretaker home Rehabilitation facility Nursing home/long-term care facility Home with hospice Shelter Other _______________________________ Unknown
Documented reason for referral to emergency department/hospital from above setting
Date of discharge (if applicable)	Not yet discharged Discharged – Date __________________
Length of stay (if applicable)	Not yet discharged Discharged – LOS __________________
Admitting chief complaint
Admitting primary diagnosis
Discharge diagnoses (primary and secondary)	Not yet discharged Discharged – Primary & secondary diagnoses ______________________________ _________________________________________
Evidence of cognitive dysfunction (delirium or dementia)	Yes _________________________________ No
Evidence of mental health issues	Yes _________________________________ No
Evidence of substance abuse issues	Yes _________________________________ No
Evidence of other chronic disease	Yes _________________________________ ______________________________________ No
Were any new medications prescribed during hospitalization that must be continued post-discharge?	Yes _________________________________ No
Evidence that a medication list (or other medication instruction) was provided to the patient	Yes No
Evidence that self-management guides, instruction, or other material was provided to the patient	Yes No
Was a follow-up (post-discharge) appointment with the PCP made?	Yes No Unknown
Are any specialist providers noted? If yes, what specialties?	Yes _______________________________ No
Was a follow-up (post-discharge) appointment made with any specialist(s)? If yes, which ones?	Yes No Unknown
What setting was the patient discharged to?	Not yet discharged Own home Home with home health Relative/caretaker home Rehabilitation facility Nursing home/long-term care facility Home with hospice Shelter Other _______________________________ Unknown

Medical Records Review (Test Strategies) Page 5

Adapted from STAAR Readmissions Diagnostic Tool