Abnormal Results Contact Attempt Record Form

Download and use this form to track abnormal Results of your patient.

Abnormal Results Contact Attempt Record Form

Text Version of this Form

Abnormal Results Contact Attempt Record

 

Please note: All attempts to contact a patient must be recorded in the patient’s individual medical record at the time of the contact. This is a legal safeguard. Practice staff MUST NOT give out test results to patients unless expressly advised to by the PCP

 

Patient’s Name
DOB
Patient’s Physical Initials
Urgency of consult
Type of test, e.g. blood, pap
Time, date, phone no. & staff initials of 1st phone call
Time, date, phone no. & staff initials of 2nd phone call
Time, date, phone no. & staff initials of 3rd phone call
Date 1st letter sent
Mail returned?
Date 2nd letter sent
Mail returned?
Date Registered Mail Sent
Post office confirmation received receipt