Dietary Oversight Readmission Rate Report Form
Report and analyze patient readmissions related to dietary oversight for quality improvement.
Patient Initials or ID (do not use full name or sensitive ID numbers)
*
Patient Age
*
Patient Gender
*
Male
Female
Other
Original Admission Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Readmission Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Department or Unit
*
Please Select
Medical
Surgical
ICU
Pediatrics
Maternity
Other
Primary Reason for Readmission
*
Dietary-related
Non-dietary-related
Unknown
Type of Dietary Oversight Identified
*
Missed dietary consult
Incorrect diet order
Food allergy not addressed
Meal delivery error
Patient non-compliance
Other
Assessment of Dietary Factors Contributing to Readmission
*
Rows
Not Contributing
Minor Contribution
Major Contribution
Malnutrition
1
2
3
Dehydration
4
5
6
Dietary restrictions not followed
7
8
9
Inadequate nutrition education
10
11
12
Other
13
14
15
Actions Taken or Planned to Address Dietary Oversight
*
Dietitian consult initiated
Diet order corrected
Patient/family education provided
Staff re-education
Process improvement initiated
Other
Staff Members Involved (select all that apply)
Dietitian
Physician
Nurse
Food service staff
Other
Additional Comments or Notes
Submit Report
Should be Empty: