36C10X19Q0200-008.docx

CASE ID

CLINICAL PEER REVIEW REQUEST

The documents, records, and other information contained herein, which resulted from Risk Management are confidential and privileged under the provisions of 38 U.S.C. § 5705, and its implementing regulations. This material cannot be disclosed to anyone without authorization as provided for by that law or its regulations. The statute provides for fines up to $20,000 for unauthorized disclosures.

Case ID:

Patient Name:

Practitioner to be reviewed:

Credential:

Service/Specialty:

Period to be reviewed:

Level of Care (select one):

· Level 1 – Most experienced and competent clinicians would have managed the case in a similar manner.

· Level 2 – Most experienced and competent clinicians might have managed the case differently, but it remains within the standard of care

· Level 3 – Most experienced and competent clinicians would have managed the case differently.

Aspects of Care (Level of Care 2 or 3 Only, select as many as appropriate):

· Choice and/or timeliness in ordering of diagnostic tests.

· Addressing abnormal results of diagnostic tests.

· Timeliness of treatment initiation and/or appropriate treatment choice.

· Performance of a procedure or treatment.

· Timeliness and/or appropriateness of diagnosis.

· Recognition and communication of critical clues to patient’s clinical condition.

· Timely initiation of appropriate actions during periods of clinical deterioration.

· Health record documentation.

· Supervision of health profession trainees.

Special Instructions:

Brief Clinical Summary/Case Overview:

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Salient Features of the Case:

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Components of Care:

1. Was the choice of diagnostic test(s) appropriate?

2. Were the test(s) ordered and performed in a timely fashion?

3. Was the management of abnormal test results appropriate?

4. Was the correct diagnosis made?

If not, what is the diagnosis?

5. Was the medical treatment appropriate?

6. Was the medical treatment completed in a timely manner?

7. Were there any complications from the procedure/surgery?

8. Was the patient monitored adequately?

9. If there was a change in the patient’s condition (e.g. clinical deterioration), was it recognized and communicated in a timely fashion?

10. If there was a change in the patient’s condition (e.g. clinical deterioration), was it appropriately managed?

11. Was the medical record documentation timely and complete?

12. Were health professional trainees (e.g. medical residents, nursing students) involved in the patient’s care?

13. Was supervision appropriate?

14. Do you have additional quality improvement suggestions?

15. Were there any system or process issues that may have influenced the clinician’s ability to provide optimal care?

16. Were established standards of care /practice consistent with current literature and relevant/current practice guidelines?

Analysis that supports Level of Care:

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Conclusions/Recommendations:

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Reference, if applicable:

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