Transition of Care Outreach Note (Post-Discharge)

Date/Time: [Date and time of outreach with time zone]

Author: [Name], [Role/Credentials]

Encounter Type: [telephone / video / patient portal / home visit / caregiver call]

Discharge Context: [Facility name]; [Discharge date]; [Discharge diagnosis]; [Disposition: home / SNF / assisted living] (If unavailable, state "Discharge details not available at time of outreach" and note sources checked.)

Reason for Outreach: [routine post-discharge check-in / high-risk readmission prevention / medication access issue / missed follow-up / symptom change reported / unable-to-reach escalation]

Outreach Attempts

(Document each attempt. For TCM billing, at least two attempts within two business days of discharge are required if two-way contact not achieved.)

• Attempt [#]: [Date/Time] | [Method] | [Number/destination] | [Outcome: reached patient / reached caregiver / voicemail left / no answer / wrong number] | [Next step if not reached] (If voicemail left, confirm message limited to callback request without clinical details.)

Contact & Patient Status

(Complete only if two-way contact achieved; otherwise proceed to Assessment & Plan for unable-to-reach escalation.)

• Contact Achieved With: [patient / caregiver / facility staff]; [Name and relationship if applicable]
• Identity Verification: [Method used prior to discussing clinical details]
• Language/Interpreter: [Primary language]; [Interpreter used: yes/no with modality if yes]
• Overall Status Since Discharge: [improved / unchanged / worse] (Use "patient reports" or "caregiver reports" attribution throughout.)
• Symptom Screen: [Key symptoms relevant to discharge diagnosis with onset, severity, actions taken] | Red flags reviewed: [Specific red flags screened and findings] (Do not default to "no red flags" unless screening was performed.)
• Patient-Reported Home Measurements: [BP, HR, SpO2, Temp, Weight as obtained] (Label clearly as patient-reported.)

Medication Review

• Medication Access: [All prescriptions obtained: yes / no / partial] | [Barriers identified] | [Actions taken to resolve]
• Reconciliation: [Lists compared] | [Status: completed / partial / deferred] (If deferred, state reason and plan for completion.)
• Discrepancies: [Medication, discrepancy type, action taken, responsible party] (Repeat for each discrepancy; state "none identified" if reconciliation completed without discrepancies.)
• High-Risk Medication Screen: [Medications reviewed] | [Safety questions addressed] | [Concerns and actions]

Follow-up & Coordination

• PCP Follow-up: [Scheduled date/time / not scheduled with barriers / scheduling action taken]
• Specialty Follow-ups: [Service(s) and status]
• Pending Results: [Labs/imaging/tests pending from hospitalization] | [Who is tracking]
• Home Health: [Ordered: yes/no] | [Start-of-care date] | [First visit status] | [Issues]
• DME: [Ordered: yes/no] | [Items and receipt status] | [Issues]
• Other Coordination: [Pharmacy, social work, transportation, community resources as applicable]

Assessment & Plan

• Clinical Stability: [stable / concerning / unstable] | Key risk drivers: [Symptoms, medication gaps, access barriers, social factors as applicable]
• Actions Completed: [Appointments scheduled, refills requested, pharmacy contacted, home health coordinated, care team notified]
• Education & Teach-back: [Topics covered] | [Teach-back result: patient able to teach back / unable to teach back and re-educated] | [Return precautions reviewed]
• Escalation: [If unstable: ED/911 instruction given, clinician notified, patient response] | [If concerning: expedited visit or close follow-up arranged] (Include only if applicable.)
• Next Steps: [Date/time of next outreach] | [Responsible team member] | [Items to recheck]
• Unable-to-Reach Escalation: [Alternate numbers tried, caregiver outreach attempted, alternate channels used, PCP notified if high-risk] | [Status: no response / message delivered / two-way contact achieved] (Complete only if patient not reached after multiple attempts.)

(Do not leave required fields blank. If information unavailable, document sources checked and plan to obtain. Do not default to "no red flags" unless symptom screening was performed.)