Transitional Care Management (TCM) Post-Discharge Follow-Up Note
A streamlined template for Transitional Care Management (TCM) face-to-face follow-up visits, capturing the required discharge details, interactive contact documentation, medication reconciliation, and problem-oriented tr…
Document Type
clinical note / Progress Note
Specialties
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Date: [Encounter date]
Patient: [Name and identifiers per local policy]
Clinician: [Rendering clinician name and credentials]
Location: [Clinic or place of service]
Discharge Date: [TCM day 0]
Interactive Contact Date: [Date of required post-discharge contact]
Contact Mode: [telephone / portal message / in-person]
TCM Episode & Hospitalization Summary
Discharging facility: [Facility name] ([hospital inpatient / SNF / rehab / LTACH / other])
Discharge diagnoses: [Primary diagnoses]
[Brief hospitalization course narrative: admission reason, major interventions, and discharge status in 2–4 sentences]
Pending results/tests: [List with responsible clinician and expected timeline] (If none, state "No pending results identified." If discharge records unavailable, note the source used and that records have been requested.)
Post-Discharge Interval History
Chief concern: [Reason for visit; include patient quote if provided]
[Interval history since discharge describing symptom trajectory, any interim healthcare visits, adherence to discharge instructions, functional status compared to baseline, support system, and relevant barriers. Identify historian if not the patient.]
Medication Reconciliation
Sources reviewed: [Discharge list / pill bottles / pharmacy records / caregiver list / EHR]
Reconciliation status: [Complete – EHR updated / Incomplete – specify outstanding items and plan to complete]
Changes since discharge: [New medications, stopped medications, and dose changes with brief indications; or "No changes"]
Discrepancies and resolution: [Differences between prescribed and actual use with resolution; or "None identified"]
Access/adherence concerns: [Barriers, side effects, or understanding issues with actions taken; or "None"]
Objective
Vitals: [Relevant vital signs]
Exam: [Problem-focused findings pertinent to hospitalization diagnoses and readmission risk]
Data: [Relevant labs, imaging, or tests since discharge and/or ordered today]
Assessment & Plan
(Use problem-oriented format ordered by severity and readmission risk. For each problem: 1–3 sentence assessment of current status vs. discharge, then specific plan including medication changes, monitoring with thresholds, diagnostics, care coordination needs, ownership of pending items, and follow-up timing. Include escalation instructions with red flags.)
[Problem 1]: [Diagnosis]
[Assessment of current status relative to discharge: improved / stable / worsened. Key risk factors for decompensation.]
[Plan: medications, monitoring parameters, diagnostics, care coordination actions, pending result ownership, patient goals, escalation red flags, and follow-up timing]
[Problem 2]: [Diagnosis]
[Assessment and plan as above; repeat for additional problems as applicable]
Care coordination summary: [Non-face-to-face work performed during TCM period: records requests, calls, specialist communication, home services arranged] (Include only if clinically relevant activities occurred beyond the interactive contact.)
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