30-Day Post-Discharge Follow-Up Call Log

Log of post-discharge calls to residents or families to track transition issues, readmission risk, and referrals back for outpatient therapy.

Call Details

• Call Date
• Caller Name
• Resident/Patient Identifier
  Use the facility or chart identifier instead of collecting full DOB or other unnecessary PII.
• Who Was Contacted?
• Call Outcome

Transition of Care Status

• Were any transition-of-care issues identified?
• Transition Issues Identified
• Issue Details
  Describe the issue(s) and any immediate guidance provided.
• Medication Concerns
• Follow-Up Appointment Status

Readmission Risk Assessment

• Readmission Risk Level
• Risk Factors Observed
• Is escalation to clinical staff needed?
• Escalation Details
  Document who was notified and what follow-up was requested.

Referrals and Follow-Up

• Referred back to outpatient therapy?
• Therapy Type
• Referral Notes
  Include scheduling status, contact information shared, or barriers to follow-through.
• Additional follow-up needed?
• Next Steps
  Describe the planned follow-up action, owner, and target date.