Form #8 Form #8 Medical record review variables

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Attachment I. Medical record review variables

1) 30-day hospital visit

2) 30 day ED visit

3) PCP appt scheduled

4

Public reporting burden for this collection of information is estimated to average 42 hours per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

) Medication reconciliation completed