"Post Operative Phone Call Sheet Template"

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POST OPERATIVE PHONE CALL SHEET
Patient Name:
________________________________________________________
Patient Number:
________________________________________________________
Phone Number:
________________________________________________________
________________________________________________________________________
Date
Respondent
Caller
General Condition stated by Patient or Significant Other:
Excellent _____ Good _____ Fair _____ Poor _____
Tolerated Diet: Yes____ No ____
Nausea/Vomiting: Yes____ No ____
Drainage from incision: Yes ____ No ____ Type: __________________Amount:___________
Fever: Yes ____ No ____
Temperature: _____
Pain: Severe ____ Moderate _____ Slight _____ None _____ Pain Medication Taken ________
Other:_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
st
1
Attempt: ____________________________________________________________________
Date
Time
Caller
Reason Not Reached
nd
2
Attempt ____________________________________________________________________
Date
Time
Caller
Reason Not Reached
rd
3
Attempt ____________________________________________________________________
Date
Time
Caller
Reason Not Reached
POST OPERATIVE PHONE CALL SHEET
Patient Name:
________________________________________________________
Patient Number:
________________________________________________________
Phone Number:
________________________________________________________
________________________________________________________________________
Date
Respondent
Caller
General Condition stated by Patient or Significant Other:
Excellent _____ Good _____ Fair _____ Poor _____
Tolerated Diet: Yes____ No ____
Nausea/Vomiting: Yes____ No ____
Drainage from incision: Yes ____ No ____ Type: __________________Amount:___________
Fever: Yes ____ No ____
Temperature: _____
Pain: Severe ____ Moderate _____ Slight _____ None _____ Pain Medication Taken ________
Other:_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
st
1
Attempt: ____________________________________________________________________
Date
Time
Caller
Reason Not Reached
nd
2
Attempt ____________________________________________________________________
Date
Time
Caller
Reason Not Reached
rd
3
Attempt ____________________________________________________________________
Date
Time
Caller
Reason Not Reached