Emergency Department Readmission Rate Report Form
Submit operational data on emergency department readmission rates for the specified reporting period. Do not include any sensitive or patient-identifying information.
Report Period Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Report Period End Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hospital/Facility Name
*
Department/Unit Name
*
Total Emergency Department Visits for the Period
*
Number of Readmissions Within the Defined Readmission Window
*
Readmission Window Used
*
7 days
14 days
30 days
Custom (specify in notes)
Primary Reason Category for Readmission
*
Clinical follow-up required
Unresolved symptoms
Complication of initial visit
Patient request
System/process issue
Other (specify in notes)
Notes on Calculation Methodology or Exclusions
Submitter Name/Title or Department
*
Submit Report
Should be Empty: