Surgical Outcome Readmission Rate Report
Report and analyze surgical case outcomes and readmission rates for quality improvement.
Patient Initials
*
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hospital/Unit Name
*
Date of Surgery
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Surgery Performed
*
Please Select
General Surgery
Orthopedic Surgery
Cardiac Surgery
Neurosurgery
Gynecological Surgery
Other
Was the patient readmitted within 30 days after surgery?
*
Yes
No
If yes, date of readmission
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Readmission
Please Select
Surgical Site Infection
Complication of Surgery
Unrelated Medical Issue
Planned Readmission
Other
Outcome after Readmission
Please Select
Recovered
Ongoing Treatment
Deteriorated
Deceased
Risk Factors or Contributing Conditions (select all that apply)
Advanced Age
Comorbidities (e.g., diabetes, hypertension)
Emergency Surgery
Prolonged Surgery
Immunosuppression
Other
Attending Surgeon Name
Additional Comments or Notes
Submit Report
Should be Empty: