AT Exhibit H Peer Review Form.pdf

EXHIBIT H

PEER REVIEW FORM

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Date of Review:

Comments for: 0

Comments for: 0

Disclosure Statement. Quality Assurance Document under 10 USC 1102. Copies of this document, enclosures thereto, and information therefrom will not be further released under penalty of the law. Unauthorized disclosure carries a statutory penalty of not more than $3,000 in the case of a first offense and not more than $20,000 in the case of a subsequent offense. In addition to these statutory penalties, unauthorized disclosure may lead to unfavorable actions under the UCMJ and /or adverse administrative action, including separation from military or civilian service.

Comments for: 0

Comments for: 0

Scoring Criteria: 0 = NO 1 = YES 1 = N/A

First Initial of Last Name + Last 4 SSN:

Date of encounter:

Is the Chief Complaint documented?

Is a history documented?

Was the patient educated regarding the assessment and plan?

Is referral documented, when necessary?

Are verbal orders from privileged provider recorded?

Are patient goals documented?

Is patient pain documented?

Is the physical exam adequate?

Are STGs and LTGs functional, objective, and timely?

Are time-based CPT codes correctly documented?

Was patient response to treatment documented?

Are correct ICD-10 codes used?

Is the Assessment supported by the S/O?

Is the follow up plan appropriate?

Is the treatment appropriate?

First Initial of Last Name + Last 4 SSNAT Reviewed:

Reviewer:

AT1