EMR Patient Feedback Request

Patient Feedback Request

Patient feedback / outcome information is available for purposes of quality review and education only - any and all information is considered to be confidential.

Gold Cross will keep 1 contact name and email on file per service (service Training Officer) and all requests for feedback will be routed securely through that contact - Only members that rendered care to a patient are able to request/receive information. If your group is not affiliated with Gold Cross please put in your directors information.

All requests for patient feedback must be accompanied by a faxed run sheet ATTN: Nick Romenesko to 920-727-3033.

Each group may request feedback on each patient no more than 2 times.

If any requests for feedback are needed for a CISD, please contact Gold Cross Dispatch immediately at 920-727-3034 to initiate the CISD response and ask them the page Nick Romenesko for urgent patient feedback.

For all other requests, please allow a minimum of 48 hours for response.

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* 1. Name of person requesting feedback

Name

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* 2. Training Officer Information

Name

Email Address

Phone Number

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* 3. Please select your group / affiliation:

Other (please specify)

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* 4. What was the Date and Time of the Call?

Date / Time

Date

Time

AM/PM

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* 5. Call Information ( Dispatch Address )

Address *

Address 2

City/Town *

ZIP/Postal Code

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* 6. Please select the reason you want patient feedback / outcome information.

So we can understand the final diagnosis and improve our assessment abilities.

So we can understand if our treatment plan was helpful for this patient.

So we can better prepare ourselves to care for this type of patient again in the future.

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* 7. Other Information or Comments:

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* 8. Run Report Upload

Please upload a copy of your run report if available in electronic form. If not you MUST follow the directions above for faxing information. A copy of the Run Report is REQUIRED to get feedback.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File