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Guide to Complaint Handling in Health Care Services

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<strong>Compla<strong>in</strong>t</strong> follow-up record<br />

(<strong>to</strong> be completed by staff member)<br />

<strong>Compla<strong>in</strong>t</strong> number<br />

1. Receipt of compla<strong>in</strong>t/feedback<br />

Date of receipt:<br />

Staff member receiv<strong>in</strong>g compla<strong>in</strong>t:<br />

Department:<br />

How was compla<strong>in</strong>t communicated? <strong>in</strong> person <strong>in</strong> writ<strong>in</strong>g telephone<br />

2. Action taken<br />

Detail immediate action taken and whether resolved at po<strong>in</strong>t of service:<br />

3. Seriousness assessment<br />

Record seriousness assessment rat<strong>in</strong>g and who referred <strong>to</strong> for action or <strong>in</strong>formation:<br />

SAM score<br />

Referred <strong>to</strong><br />

4 Local level<br />

<strong>Compla<strong>in</strong>t</strong>s manager<br />

3 Local level<br />

<strong>Compla<strong>in</strong>t</strong>s manager<br />

Department manager<br />

2/1 <strong>Compla<strong>in</strong>t</strong>s manager<br />

Department manager<br />

Executive management<br />

Quality team<br />

DOM, DON<br />

Follow up required? By whom?<br />

Sett<strong>in</strong>g up your system/<strong>to</strong>ols 41

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