Form #2 Medical Records Review Tool (Test Strategies)

Adapting Best Practices for Medicaid Readmissions

Attachment B -- Medical Records Review Tool (Test Strategies)

Medical records review

OMB: 0935-0204

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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

  1. Age


  1. Gender

Male

Female

  1. Marital status

Married/partnered

Widowed

Separated

Divorced

Single

Unknown

  1. Are patient Hispanic or Latino/Latina?

Yes No

  1. 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

  1. Patient’s primary language spoken at home

_____________________

Unknown

  1. Housing status

Own

Rent

Live in someone else’s home

Shelter

Other _______________________

Unknown

  1. Payer

Medicaid

Medicaid Managed Care Organization or Health Maintenance

Medicaid and Medicare

Other – NOT ELIGIBLE

  1. Number of hospitalizations (observation or inpatient) in past 12 months


  1. Number of emergency department visits in past 12 months


  1. Note any documentation of the patient’s social supports, language/ cultural/ economic factors that may affect his/her ability to transition from the hospital


  1. Note any documentation of the patient’s functional status (ability to attend to activities of daily living (ADLs) and instrumental ADL


  1. Is a primary care provider (PCP) noted in the chart?

Yes No


  1. 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

  1. Date of admission


  1. Date of discharge


  1. Length of stay


  1. Admitting chief complaint


  1. Admitting primary diagnosis


  1. Discharge diagnoses (primary and secondary)


  1. Evidence of cognitive dysfunction (delirium or dementia)

Yes _________________________________

No

Not addressed

  1. Evidence of mental health issues

Yes _________________________________

No

Not addressed

  1. Evidence of substance abuse issues

Yes _________________________________

No

Not addressed

  1. Evidence of other chronic diseases

Yes _________________________________

_____________________________________

No

  1. Were any new medications prescribed during hospitalization that must be continued post-discharge?

Yes _________________________________

No


  1. Evidence that a medication list (or other medication instruction) was provided to the patient

Yes No

  1. Evidence that self-management guides, instruction, or other material was provided to the patient

Yes No

  1. Was a follow-up (post-discharge) appointment with the PCP made?

Yes No Unknown


  1. Are any specialist providers noted? If yes, what specialties?

Yes _______________________________

No

  1. Was a follow-up (post-discharge) appointment made with any specialist(s)? If yes, which ones?

Yes No Unknown


  1. 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

  1. Date of admission


  1. 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

  1. Documented reason for referral to emergency department/hospital from above setting


  1. Date of discharge (if applicable)

Not yet discharged

Discharged – Date __________________

  1. Length of stay (if applicable)

Not yet discharged

Discharged – LOS __________________

  1. Admitting chief complaint


  1. Admitting primary diagnosis


  1. Discharge diagnoses (primary and secondary)

Not yet discharged

Discharged – Primary & secondary diagnoses ______________________________

_________________________________________

  1. Evidence of cognitive dysfunction (delirium or dementia)

Yes _________________________________

No

  1. Evidence of mental health issues

Yes _________________________________

No

  1. Evidence of substance abuse issues

Yes _________________________________

No

  1. Evidence of other chronic disease

Yes _________________________________

______________________________________

No

  1. Were any new medications prescribed during hospitalization that must be continued post-discharge?

Yes _________________________________

No

  1. Evidence that a medication list (or other medication instruction) was provided to the patient

Yes No

  1. Evidence that self-management guides, instruction, or other material was provided to the patient

Yes No

  1. Was a follow-up (post-discharge) appointment with the PCP made?

Yes No Unknown


  1. Are any specialist providers noted? If yes, what specialties?

Yes _______________________________

No

  1. Was a follow-up (post-discharge) appointment made with any specialist(s)? If yes, which ones?

Yes No Unknown


  1. 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

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