Pharmacy Review Readmission Rate Report Form
Submit your pharmacy's readmission rate review with key metrics, factors, and follow-up actions.
Hospital or Pharmacy Name
*
Facility Identifier (e.g., NPI, Internal ID)
*
Reporting Period
*
Please Select
Q1 (Jan-Mar)
Q2 (Apr-Jun)
Q3 (Jul-Sep)
Q4 (Oct-Dec)
Full Year
Other (please specify)
Review Type
*
Routine Review
Targeted Review
Follow-up Review
Other (please specify)
Total Number of Discharges During Reporting Period
*
Number of Readmissions Within 30 Days
*
Primary Contributing Factors to Readmissions
*
Medication Non-adherence
Adverse Drug Events
Inadequate Discharge Planning
Lack of Follow-up Care
Patient Socioeconomic Factors
Other (please specify)
Actions Taken to Reduce Readmission Rates
*
Medication Reconciliation
Patient Education/Counseling
Enhanced Discharge Planning
Follow-up Calls/Visits
Care Coordination with Providers
Other (please specify)
Observed Barriers or Challenges During Review
Reviewer Name and Position
*
Submit Report
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