Patient Readmission Rate Report Form
Report and analyze patient readmissions to improve healthcare outcomes.
Patient Initials (Do not enter full name or sensitive identifiers)
*
Patient Age
*
Patient Gender
*
Male
Female
Other
Date of Initial Admission
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Department/Unit of Initial Admission
*
Please Select
Internal Medicine
Surgery
Pediatrics
Obstetrics & Gynecology
Emergency
Other
Primary Diagnosis at Initial Admission
*
Date of Readmission
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Department/Unit of Readmission
*
Please Select
Internal Medicine
Surgery
Pediatrics
Obstetrics & Gynecology
Emergency
Other
Primary Reason for Readmission
*
Please Select
Complication of previous condition
New unrelated condition
Medication issue
Infection
Patient non-compliance
Other
Time Between Discharge and Readmission (in days)
*
Was the readmission potentially preventable?
*
Yes
No
Uncertain
Contributing Factors (select all that apply)
Discharge planning issues
Follow-up care unavailable
Medication error
Patient non-compliance
Social factors
Other
Outcome of Readmission
*
Please Select
Discharged home
Transferred to another facility
Ongoing inpatient care
Deceased
Staff Member Reporting
*
Additional Comments or Notes
Submit Report
Should be Empty: