Data Collection – Hospital Readmission/ER Visit

Purpose: This form is intended to track the number and characteristics of all unplanned nursing home resident transfers or visits to the hospital or emergency room.

Whenever an unplanned hospital transfer or ER visit occurs record the requested data on the Hospital Readmission/ER Visit Data Collection form. This form is on Excel, is designed to be used electronically and requires Excel software.

Some columns should be answered by choosing from a drop-down list. Those columns are indicated with an * (asterisk).

Do not count urgent care visits unless they result in a hospital admission, observation days or ER visit.

Instructions for completing the form:

Enter facility name and the month and year

Enter the name and phone number of the person completing the form.

Enter total resident days this month (A).

Enter the number of residents admitted to your nursing home this month (B).

For each unplanned hospital admission, ER visit or observation day stay, enter the following, each on a separate line:

  1. Enter Resident’s identifier. The identifier is usually the resident’s nursing home medical record number.
  2. Enter resident’s age at the time of the transfer.
  3. Enter the date of the resident’s most recent admission (not hospital return) to your facility. Use __/__/__ format to enter the date.
  4. List the dates of hospitalizations and ER visits in the past year or since

admission if less than a year. If there is more than one, use the next line

for each additional date and corresponding diagnosis.

5. List the corresponding primary hospital admitting or ER diagnosis for each

visit listed in #4. Choose from the drop down list by clicking on the cell

and then the arrow beside the cell. Choose CHF, Fever, Pneumonia,

Dehydration, Acute Mental Status Change, or Other.

  1. Choose from drop down whether the resident is in the facility for a short term or long term stay.
  2. Choose the payer for the resident’s nursing home stay.

8. Enter the date of the transfer/visit. Use __/__/__ format.

9. The day of the week will be automatically populated.

10. Choose the time of the transfer.

  1. Choose yes or no if the resident was sent following a 911 call.
  2. Write in the name of the doctor, NP or PA who gave the order to send the resident to the hospital/ER.
  3. Choose yes or no if this doctor/NP/PA is the resident’s primary physician. Do not answer yes if it is the on-call provider from the resident’s own clinic.
  4. Enter the name of the resident’s/attending physician’s clinic or provider network if there is no clinic. (ie North Clinic or Allina,).
  5. Choose from the dropdown the hospital to which the resident was sent.
  6. Choose whether the resident was admitted, placed on observation or seen in the ER and sent back to the nursing home.
  7. Enter the hospital admitting/ER diagnoses. Choose from the list: CHF, Fever, Pneumonia, Dehydration, Acute Mental Status Change, UTI or Other.

Areas in yellow will auto-populate to calculate all readmissions and 30 day readmissions per 1000 resident days and per 1000 nursing home admissions.

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