Patient Grievance Intake and Resolution Log

Log to capture patient grievances, track resolution steps, and report outcomes to support QI/QA oversight in an FQHC or similar care setting.

Submission Notice

• How is this grievance being submitted?
• Consent to be contacted about this grievance
  Select this if the patient or representative agrees to follow-up contact for clarification or resolution updates.
• Preferred contact method
• Brief summary of the grievance
  Provide a short summary of what happened and what outcome is being requested, if known.

Patient and Contact Information

• Patient name
• Patient date of birth
  Only collect if needed to identify the correct patient record.
• Medical record number
  Optional. Do not collect if another identifier is sufficient.
• Contact phone
• Contact email

Grievance Details

• Date of incident or concern
• Date grievance was reported
• Service area involved
• Grievance category
• Detailed description
  Include only relevant facts, dates, locations, and people involved. Avoid unnecessary PHI.

Triage and Resolution Tracking

• Priority level
• Assigned owner
  Name or role responsible for investigation and follow-up.
• Date assigned
• Investigation steps taken
  Summarize interviews, record review, service recovery actions, and any coordination completed.
• Corrective action or service recovery
  Document actions taken to address the grievance and prevent recurrence.
• Resolution status
• Resolution date

Outcome and QI/QA Review

• Outcome summary
  Briefly describe the final outcome communicated to the patient or representative, if applicable.
• Follow-up needed
• Refer to QI/QA review
  Select if the grievance indicates a trend, system issue, or potential improvement opportunity.
• QI/QA review notes

Audit Trail

• Submitted by
• Submission timestamp
• Last updated by
• Last updated timestamp