Form 0917-0036 Patient Flow Time Study

Form Approved

OMB Form No. 0917-0036

Expiration Date:

Patient Flow Time Study

In an effort to improve patient flow we are conducting a survey throughout each point of contact. As you reach each point of contact the appropriate staff will sign or initial this form before the start of each process. Please double check the time to make this study as accurate as possible, if there are any discrepancies please let us know.

Please return this form back to patient registration after you have been discharged from your providers care and all ancillary tests (X-ray/lab) have been completed.

Provider: ______________ HR #: _____________

Date: Appointment Time: _______________

Primary Care Clinic

1) Checked in with Patient Registration

Time: _____________ Patient Registration Signature: _________________________________

2) Screened by Nurse (Vitals)

Time: _____________ Screening Nurse/Aide Signature: _______________________________

3) Placed in room by nurse

Time: _____________ Screening Nurse/Aide Signature: _______________________________

4) Medication Reconciliation/Nurse Assessment

Time: _____________ Screening Nurse Signature: ____________________________________

5) Examined by Medical Provider

Time: ______________ Medical Provider Signature: ____________________________________

Laboratory and/or Radiology

1. Sent to Lab

Time: ____________ PC or Lab Staff Signature: _____________________________

b) Return from Lab

Time: ____________ PC or Lab Staff Signature: _____________________________

c) Sent to Radiology (X-Ray/CT Scan/Ultrasound)

Time: ____________ PC or Radiology Staff Signature: ___________________________

d) Return from Radiology

Time: ____________ PC or Radiology Staff Signature: ___________________________

6) Patient Discharged from Primary Care

Time: _________ Medical Provider/Nurse Signature: ______________________________

7) Check-Out with Patient Registration to complete visit and/or schedule a follow-up

Time: _________ Patient Registration Signature: _________________________________

Please stop at Patient Registration to check-out after your visit.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The   valid OMB control number for this information collection is 0917-0036.  The time required to complete this information collection is estimated to average five minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.