Clinician Auditing Feedback Form – AdaptIT

Question 1 of 1

Stage

What stage is this audit for?

Question 2 of 1

Level

Which level are you auditing?

Question 3 of 1

Role

What is your role?

Question 4 of 1

Pro Mode

Enable Pro fields for detailed metrics?

No Yes

Baseline Metrics

Baseline Metrics

Current Tools (Select all that apply)

EHR vendor Telehealth tool RPM vendor Spreadsheets Paper Other

Baseline Charting Time per Encounter (minutes)

Baseline Follow-up Completion (%)

Baseline Readmit Rate, Target Cohort (%)

Audit-readiness Hours per Month

Patient Mix (must total 100%)

% English

% Spanish

% Other

Midpoint Metrics

Midpoint Metrics

Charting Time Now (minutes)

Charting Time Change vs Baseline

Follow-up Completion Now (%)

Follow-up Change Band

Readmits Now (%)

Adoption: % Clinicians Using Feature Weekly

Top Blocker This Period

Issues Encountered (Select all that apply)

Performance Usability Training Connectivity Integration Security/Privacy Other

Issue Severity

Resolution ETA

Final Outcomes

Final Outcomes

KPI Outcomes (Auto-calculated notes)

Audit-readiness Hours Now

Expansion Readiness

Ready to L3+ Not yet

Prerequisites

Go/No-Go by Role

Reason

L1 - Telehealth

Front Desk

Bookings per Day

No-show/Reschedule Rate

Reminder Ease

1

2

3

4

5

Friction This Week

Pro Fields

Avg Reschedule/Cancel Handling Time (minutes)

Reminder Channel Mix

SMS Email Portal Call

Bilingual Consent Edge Cases

Clinician

Visits Starting on Time

Reminder Accuracy

1

2

3

4

5

Notes

Pro Fields

Micro Time Study per Visit

Pre-chart

Visit

Post-chart

% Visits Where Reminder Prevented Delay

Top 2 Workflow Fixes

Coordinator/Admin

Manual Steps Removed vs Baseline

1

2

3

4

5

Consent/Privacy Issues

No Yes

Notes

L3 - RPM

Nurse/MA

Devices Onboarded

Avg Onboarding Time

Most Common Issue

Need Additional Devices?

No Yes

Device Type Quantity Needed By

Pro Fields

Failure-mode Checklist

Pairing fail BLE drop Wi-Fi auth Patient steps unclear Firmware

% Daily Reading Goal Met

Clinician

Alert Usefulness

1

2

3

4

5

False Alerts This Week

Alert Changed Care Decision?

No Yes

Example

Pro Fields

Recommended Threshold Tweak

IT/EHR

Network/Connectivity Incidents

Security Concerns Flagged?

No Yes

Notes

Incident Details

Incident ID

Severity

Description

Timestamp

Owner

Mitigation Steps

Status

RCA Link (URL, optional)

✅

Audit Submitted!

Thank you for your feedback. Your audit submission has been received and will be reviewed by the team.

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