Telehealth Analysis Readmission Rate Report
Report form for analyzing patient readmission rates following telehealth encounters.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Initial Telehealth Encounter
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Date of Readmission
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Reason for Readmission
*
Please Select
Complication related to initial condition
New unrelated condition
Medication issue
Lack of follow-up
Patient non-compliance
Other
Was the readmission preventable?
*
Yes
No
Uncertain
Factors Contributing to Readmission (select all that apply)
Access to care barriers
Communication issues
Technology limitations
Inadequate follow-up
Patient understanding
Other
Rate the effectiveness of the initial telehealth encounter
*
Not effective
1
2
3
4
Highly effective
5
1 is Not effective, 5 is Highly effective
Provider's Assessment and Recommendations
Additional Comments
Provider Signature
*
Submit Report
Submit Report
Should be Empty: