St. Vincent Charity Data Tracking
Are you tracking an encounter?
Yes
No
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Staff Name
First Name
Last Name
Round Information
Please share details about your rounds every 30 - 45 minutes
Area of hospital visited:
Who did you visit and what were their first names?
Did you educate anyone on Thrive Programs - please list their first names?
Encounter/Engage/Refer/Link
This is where you track information on patients that you are asked to see.
Where was patient encounter requested and the name of the person requesting engagement?
Was the patient open to engagement?
Yes
No
Did you encounter any barriers attempting engagement?
Yes
No
If yes, please explain
Did you provide the patient with any referrals during your engagement?
Yes
No
What referrals did you provide:
Medication Assisted Treatment
Recovery Housing
Residential Treatement
Intensive Outpatient Services
Partial Hospitalization Program
Detox
Food
Transportation
Housing (not recovery based)
Community Resources
Clothing
Peer Support
Harm Reduction Services
Primary Care
Dental
Other
Did you provide the patient with any linkage during your visit?
Yes
No
Please list names of places you provided the patient with:
Did you transport the patient anywhere?
Yes
No
Where did you transport the patient?
Please list the time you spent with the patient:
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
05
10
15
20
25
30
35
40
45
50
55
Minutes
AM
PM
AM/PM Option
Until
until
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
05
10
15
20
25
30
35
40
45
50
55
Minutes
AM
PM
AM/PM Option
Barriers
Successes
Submit Form
Should be Empty: