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Run: Patient Grievance Intake and Resolution Log

Track patient grievances from intake through resolution in one log built for FQHC and clinic QI/QA review. Capture only the contact and case details needed t...

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Submission Notice

How is this grievance being submitted? (required)

Consent to be contacted about this grievance

Select this if the patient or representative agrees to follow-up contact for clarification or resolution updates.

Yes No N/A

Preferred contact method

Brief summary of the grievance (required)

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 (required)

Service area involved (required)

Grievance category (required)

Detailed description (required)

Include only relevant facts, dates, locations, and people involved. Avoid unnecessary PHI.

Triage and Resolution Tracking

Priority level (required)

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 (required)

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

Yes No N/A

Refer to QI/QA review

Select if the grievance indicates a trend, system issue, or potential improvement opportunity.

Yes No N/A

QI/QA review notes

Audit Trail

Submitted by

Submission timestamp

Last updated by

Last updated timestamp

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Email (required)

Your name (optional)

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