JRP Class Forms- KNEE- Jan2024

JRP Class Forms- Knee- Jan2023
Pomona Valley Hospital Medical Center (PVHMC) is committed to providing
excellent care with quality outcomes to our patients.

PVHMC participates in the American Joint Replacement Registry (AJRR) by
submitting data. Their mission is to improve the care for patients having joint
replacement surgery of the hip and knee. “By collecting and reporting data, AJRR
provides actionable information to guide physicians and patient decision making
to improve care.”

For those with Medicare, we are mandated to collect and report data with
outcomes as part of the Comprehensive Care for Joint Replacement (CJR) Model.
Their model aims to support better and more efficient care for those undergoing hip
and knee replacements.

Please complete the following surveys. Please fill them out completely before
turning them in. It is very important that each question is answered. You will be
asked in 90 days and 1-year post surgery to re-submit these surveys to track your
overall improvement.

Attestation: In completing the following surveys you are attesting that you have attended an in-person or on-line PVHMC Total Joint Replacement class with in a year of your scheduled surgery

Thank you and we wish you a speedy recovery

Aimee Castillejo, MSN, RN, CEN
Quality Clinical Coordinator
(909) 630-7403

Ana Marrero, MSN, APRN, FNP-C
Quality Clinical Coordinator, Nurse Practitioner
(909) 630-7815

Patient Information
Patient Name*

First NameLast Name
Date

MonthDayYear
Date
Date Of Birth*

MonthDayYear
Date
Email*
example@example.com
Date of Class (In person or online)*

MonthDayYear
Date
Date of Surgery*

MonthDayYear
Date
Surgeon's Name
Location of surgery:*

RightLeft
Coach's Name

First NameLast Name
Coach's Phone Number
Please enter a valid phone number.
Goal of Surgery*
What do you hope to achieve after joint replacement surgery?