Attachment B - Patient Tracking Log

PNDP Data Elements – Tracking Log
OMB # 0915-XXXX

Navigated Patient Tracking Log Form Example
Subject ID: __________________________

Date of Activity: ____________

Patient Navigator: _____________________

Time of Activity: ____________

1. Characteristics of Communication
Type
(Check only one)
Telephone call
Home meeting
Face-to-face meeting at clinic
Accompaniment to healthcare visit
Accompaniment to social service site
Accompaniment to community org
Written (email/letter)
Other: _____________

Person(s) Involved:
(Check all that apply)
Patient
Social network (family, friends, etc.)
Healthcare provider
Healthcare staff
Community resource staff
Other: _____________

Reason for communication:
(Check all that apply)
Reminder call
Patient Education
Schedule health care appt.
Schedule other appointment
Arrange for medical records
Arrange for transportation
Other arrangements

2. Patient Navigator Activities (Check All That Apply):
Coordinate health care services/ referrals
Assist patient overcome barriers
(screening and/or treatment)
Coordinate health care coverage
Facilitate involvement of community organizations
Assist in seeking preventative care
Notify and coordinate clinical trials

Barriers Addressed (Check All That Apply):
Transportation
Language/Interpreter
Housing
Literacy
Childcare issues
Communication concerns with medical personnel
Location of healthcare provider
System problems with scheduling care
Out of town/country
Medical/mental health comorbidity
Patient disability
Insurance/high copay
Fear

Financial problems
Employment issues
Perceptions about tests/treatment
Attitudes toward providers
No barriers identified
Other__________

4. Referrals Facilitated Today (Navigation Targets) (Check All That Apply):
Screening
Social services
Treatment
Community organization (Type_____________________)
Pharmacy assistance program
Clinical trial
Health care coverage programs
Other__________

Public Burden Statement: 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. The OMB control number for this project is 0915-xxxx. Public reporting burden for this collection of
information is estimated to average xx hours per response, including the time for reviewing instructions, searching existing data sources, and
completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland,
20857.

PNDP Data Elements – Tracking Log
OMB # 0915-XXXX

5. Program status (Check Only One):
Navigation in progress
Patient refused navigation
Patient cannot be reached/Lost to navigation

OR Navigation complete:
Screening complete; negative finding
Followup test complete; negative finding
Completed treatment
Achieved other target __________________

Visits Reported Since Last Patient Contact:
Screening Date: __________

Hospital Stay (# Days): __________

Specialist Visit Dates: __________

Clinical Trial Attempt: __________

Primary Care Visit :__________

Social Service Visit: __________

Emergency Room Visit: __________

Community Organization Meetings: __________

Public Burden Statement: 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. The OMB control number for this project is 0915-xxxx. Public reporting burden for this collection of
information is estimated to average xx hours per response, including the time for reviewing instructions, searching existing data sources, and
completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland,
20857.