Emergency Call Log

Call log from patient advisor, doctor or nurse speaking to a patient remotely about a post procedure problem. This MUST be filled in immediately following any such call.

On completion of the form the Clinic Manager, Medical Directors and Patient Advisory Team will be automatically notified of the form completion.

NB. Before calling patient gather all soon available relevant information e.g. copies of clinic letters

1.

Date of Call *

/ / (dd/mm/yyyy)

2.

Time of Call: *

3.

Patient ID:

4.

Patient Initials *

5.

What clinic did the patient attend?

6.

Were you speaking to the patient directly? *

Yes
No
Other, please specify Other, please specify

7.

If no, who were you speaking with?

Name

Relationship to Patient

1/3