Veteran Affairs Readmission Rate Report Form
Use this form to report and review readmission rates, contributing factors, and follow-up actions for a Veteran Affairs facility or department.
Reporting Details
Facility / Hospital Name
*
Facility Type / Department
*
Please Select
Hospital
Clinic
Outpatient Center
Emergency Department
Veterans Affairs Medical Center
Other
Facility Location / Region
*
Reporting Period
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Report Submitted Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Readmission Metrics
Total Discharges During Reporting Period
*
Total Readmissions Within Readmission Window
*
Readmission Window Used
*
7 days
14 days
30 days
Other
Readmission Rate Percentage
Calculation Notes
Case Characteristics
Primary condition/category associated with readmission
*
Please Select
Cardiovascular
Respiratory
Infectious disease
Gastrointestinal
Neurological
Mental health
Orthopedic
Post-surgical
Other
Top reason for readmission
*
Medication issue
Follow-up care gap
Complication
Worsening condition
Social support issue
Other
Reason category counts and comments
Rows
Count
Comments
Medication issue
Follow-up care gap
Complication
Worsening condition
Social support issue
Other
Brief contributing factors / observations
Follow-up and Action Plan
Current interventions or follow-up actions in place
*
Discharge instructions review
Medication reconciliation
Follow-up appointment scheduling
Care coordination
Patient outreach
Other
Action owner / responsible team
*
Target completion date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional recommendations
Reporter Information
Reporter Name
*
Job Title / Role
*
Department / Unit
*
Work Email
*
example@example.com
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Report
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