Staff Support Client Escalation Form-Staff Use Only

Staff Support Client Escalation Form-Staff Use Only

USE THIS FORM TO REQUEST ASSISTANCE FROM CLIENT SERVICES MANAGER REGARDING:

inappropriate client behavior
abusive/inappropriate treatment of our staff
any client escalations that are interfering with the ability to care for our patients
any client that needs to speak with management in order to continue patient care
possible or definite termination of the VCPR

Today's Date*

Priority*

How negatively is this affecting the staff?

Select or enter value

Client ID# & Full Name*

Name of the client(s) the escalation is regarding

Patient ID and Name*

Associated Appointment Date + Clinical Record ID#*

So that I will know where to start when reviewing client/patient records in Ezyvet

Department(s)*

Department(s) involved in and/or witness to client behavior.

Select or enter value

Staff Members Involved*

Any staff members that

witnessed this escalation
can provide information about client behavior, contributing factors/explanations of the cause of the escalation
may be able to assist in resolving this issue.

Grievance Details*

Provide a summary of any/all concerns and information that may not be found in Ezyvet or other communications. Include events leading up to/reason this needed to be escalated to management. What happened?

Reasonable Solution/Outcome*

What type of assistance is needed? A phone call with the client to discuss boundaries/expectations of client behavior in order to continue patient care? Termination of the VCPR? Please specify.

Send me a copy of my responses

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