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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool10_dc_checklist.docx
November 01, 2015 - A discharge plan for all inpatients and observation patients
As specified in the November 2015 proposed … The patient’s condition at discharge
Include cognitive function.*
Include functional status.*
Include … Specifically address comorbid behavioral health conditions
Include plan for followup care for behavioral … A brief description of care instructions
Customized instructions for self-care.*
Consistent with the … Effective linkage of patients to posthospital clinical, behavioral, and social services
The hospital
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www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/redtool5.html
March 01, 2025 - All RED patients should be called 2 to 3 days after discharge by a member of the clinical staff. … Understanding of how to manage any medical changes or whether he or she needs to seek medical care for … Advising the patient to go to urgent care or the emergency department. … When a patient is not following the treatment plan due to difficulty understanding the plan or an inability … Smith on September 20, 2012, in order to discuss his condition and medicines.
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www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool5.html
March 01, 2025 - All RED patients should be called 2 to 3 days after discharge by a member of the clinical staff. … Understanding of how to manage any medical changes or whether he or she needs to seek medical care for … Advising the patient to go to urgent care or the emergency department. … When a patient is not following the treatment plan due to difficulty understanding the plan or an inability … Smith on September 20, 2012, in order to discuss his condition and medicines.
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www.ahrq.gov/research/findings/final-reports/diabetesnetwork/diabnet1.html
October 01, 2014 - Summary
Mi Plan de Acción
My Action Plan
Spanish Chronic Disease Self-Efficacy Scale … condition, the expectation is that these projects will provide knowledge that can be used to decrease … A central concept in self-management is self-efficacy, or patient confidence to carry out a behavior … In a clinical setting the process begins with bi-directional communication between the provider and the … Clinical champion(s) for a patient self-management initiative.
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www.ahrq.gov/sites/default/files/publications/files/interimhacrate2013_0.pdf
October 27, 2014 - stay, permanent harm, a life-sustaining intervention, or death. … HCUP databases are derived from administrative data and contain encounter-
level, clinical, and nonclinical … The abstraction protocol used for MPSMS has only undergone minor changes since the PfP measurement plan … HHS Action Plan to Prevent Healthcare-Associated Infections.
2009. http://www.hhs.gov/ash/initiatives … Antithrombotic therapy for venous thromboembolic disease: American
College of Chest Physicians Evidence-Based Clinical
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www.ahrq.gov/es/patient-safety/settings/hospital/red/toolkit/redtool3a.html
March 01, 2025 - Reason for specialist/test/lab (e.g., arthritis, heart condition). … Coach your patient on what might be normal difficulties associated with his or her condition (e.g., with … clinical information and proper ongoing care of active medical issues is in jeopardy. … This is a significant patient safety and clinical quality issue. … Advanced care planning: Patients who have not assigned a health care proxy or established advanced directives
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www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool3a.html
March 01, 2025 - Reason for specialist/test/lab (e.g., arthritis, heart condition). … Coach your patient on what might be normal difficulties associated with his or her condition (e.g., with … clinical information and proper ongoing care of active medical issues is in jeopardy. … This is a significant patient safety and clinical quality issue. … Advanced care planning: Patients who have not assigned a health care proxy or established advanced directives
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/opennotes-1.pdf
May 01, 2016 - This can lead to confusion about the diagnosis, the
care plan, and any necessary followup activities … Communication lapses between the
patient and provider may lead to misunderstanding
about the care plan … Access to the clinical notes may help prevent harm,
for example, from missed tests or followup. … one clear benefit of OpenNotes is
greater patient understanding of the plan of care,
including clarity … Base
on the notes, the patient may have questions about
the plan of care or a safety concern or may
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/hospital/compare/WR_751_AHRQ_Quigley_08_26_10.pdf
April 01, 2010 - • If you had any anxieties or fears about your condition or treatment, did a nurse
discuss them with … fears
about your condition or treatment, did a nurse discuss them with you?” … • If you had any anxieties or fears about your condition or treatment, did a nurse
discuss them with … • If you had any anxieties or fears about your condition or treatment, did a nurse
discuss them with … or the action
plan.
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www.ahrq.gov/sites/default/files/2025-03/isbell-boudreaux-report.pdf
January 01, 2025 - along with a treatment plan. … (2)
satisfied/pleased, or (3) they were not asked to complete this task (control condition). … care, diagnostic
and clinical errors). … We found no evidence that diagnostic error or treatment
plan quality varied as a function of either … Medical Care for Patients with
Mental Health and/or Substance-Use Disorders: A Qualitative Investigation
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www.ahrq.gov/sites/default/files/wysiwyg/topics/dx-safety-workgroup-meeting-notes-jul2023.pdf
November 03, 2023 - excellence: DLS recently
published The Clinical Laboratory Is an Integral Component to
Health Care … DLS is
developing a communications plan to reach the nation’s
laboratories, laboratory and clinical … College of Emergency Physicians]
o Patients with symptoms consistent with a possible emergency
health condition … they have an emergency or
nonemergent medical condition) based on the patient’s symptoms
when they … The current plan is for the IAWG Subcommittee to continue
to incorporate edits for the final draft
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/multichronic/mcc.html
May 01, 2025 - The Challenge Although prevalence varies with definition, MCC is the most common chronic condition seen … in clinical practice. … Service Organizations Rapid Scan Report (PDF, 1 MB) Measures Rapid Scan Report (PDF, 602 KB) eCare Plan … for Multiple Chronic Conditions AHRQ's eCare Plan project aims to build care planning tools that will … chronic physical or mental health conditions .
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK1_T4-Urinalysis_and_UTIs_Improving_Care-updated.pdf
October 01, 2016 - • It is an approach to providing healthier and safer care to residents. … — Pharmacists need to know the resident’s condition to avoid medication errors. … PA about symptoms and the resident’s condition. … — SBAR can help nursing home staff document a resident’s condition to make it easier to
determine … Assessment Input
— The “assessment input” component identifies specific criteria needed to make a
clinical
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety_facguide.docx
May 01, 2017 - Units can customize, adapt, and tailor the specific clinical guidance or instructions on the checklist … based on unit preferences, best practices, or emerging clinical evidence. … patient condition, errors in dosing, etc.) will be caught by a check or team alert when it occurs. … or maternal distress, and knowing the plan for a timely response to prevent further deterioration. … Communicating during transitions of care helps to assure a shared mental model of the plan of care and
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/handouts2.html
December 01, 2017 - Care Plan Meetings
X
2. Dietary Department Internal Review
X
3. … Care Plan Meetings
X
2. CNA Shift Change Report
X
3. … Care Plan Meetings
X
2. CNA Shift Change Report
X
3. … , Functional, and Intervention Profile Report
Care Plan Meetings
Weekly review of resident care … status and residents' care plan interventions for CNA followup.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/menu.html
December 01, 2017 - of potential ways facility teams may choose to integrate the pressure ulcer prevention reports into clinical … Other
Resident Clinical, Functional, and Intervention Profile Report – 4-Week View
… Resident change in condition reviews
2. … Care plan meetings
4. Weekly wound review meetings
5. … Restorative care review
6. Nutrition review
7.
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-89-adhd-behavior-section-5-attach-5.pdf
February 02, 2012 - The primary care clinician should recognize ADHD as a chronic
condition and, therefore, consider children … The school environment,
program, or placement is a part
of any treatment plan.
c. … These
clinical options are interventions
that a reasonable health care pro-
vider might or might not … If a diagnosis
of ADHD or other condition is made
by a subspecialist, the primary care
clinician should … The school environ-
ment, program, or placement is a
part of any treatment plan.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/bethellscreener.pdf
February 01, 2002 - need 1) has or is at risk for having a physical, de-
velopmental, behavioral, or emotional condition … dependency on devices or medication was due to a med-
ical, behavioral, or other health condition that … Is this because of ANY medical, behavioral, or other health condition? … Is this because of ANY medical, behavioral, or other health condition? … Is this because of ANY medical, behavioral, or other health condition?
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/medread-tools.pdf
July 28, 2016 - ” or other clinical readmission risk
Identify the “learner” or care plan partner to include in education … PLAN TEMPLATE
Patient Name
Patient MRN
DOB / Age / Gender
Care plan date
Date care plan created … or life-threatening condition]
• [Attempt to treat symptomatic pain without the use of narcotics] … PLAN EXAMPLE 2
This is an example of a “Complex Care Plan” (ED Care Plan) that is currently in use … Patient:
Age/Sex:
MRN#:
DOB:
[Acute or ED] Care Plan
Care Plan Date:
• [date plan was created
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-244-fullreport.pdf
December 01, 2019 - • Prevalence of condition among children under age 21 and/or among pregnant
women. … • Fiscal burden of measure focus (e.g., clinical condition) on patients, families, public
and private … Health plan*: Can compare quality of care among health plans. … Adult depression in primary care. Clinical Guideline. … Depression, Adult in Primary Care. Clinical guideline.