Attachment B - WSEC Template.docx

Veteran Last Name Specialty Sample WSEC

Cover sheet OMLA notification number ____________

CPP name ___________________________ Specialty ______________________

Veteran’s name_[provided by OMLA]__________________________________

Involved VA facility (s)_[Provided by OMLA]____________________________

Allegation: This is developed by the VA legal department during their claim preparation prior to payment and provided to OMLA with the payment notification. OMLA will provide this to the Contractor. If the allegation is not sufficiently broad or developed to represent the issue being evaluated, the Contractor is to expand it to better represent the issue. For example, an allegation of “delay in diagnosis” is not sufficient, but an allegation of “delay in diagnosis of lung cancer” is sufficient.

List of Review Materials provided by OMLA (includes additional information provided)

Non-VA Records, Policies, Administrative Board Investigations Number of CDs with imaging studies (can be omitted if none)

Practitioner Statements:

Name, specialty, [if trainee status, supervising physician] and if a statement was provided (repeat as needed)

[Insert page break after this section]

Summary of Care (1-3 pages)

The Summary of Care section has three sections: Brief summary of incident, Pertinent past medical history, Chronology of the episode of care. This is to be developed as a stand-alone middle portion of the WSEC.

This section will be provided as an attachment to the Review Panel Summary of Conclusion letter provided by Director, OMLA to the involved VA medical center. Only this section of the facts of the case is provided to the involved Facility. The facts of the case are already known to the involved medical center. The Contractor’s company name may or may not be noted in the header, per the Contractor’s discretion.

Brief Summary of Incident This section is a more thorough expansion of the incident under review and is usually several sentences.

Pertinent past medical history

This is a xx year old patient with a history of…..)

Chronology of the episode of care (The episode of care is broadly defined as care provided at relevant health care encounters associated with the outcome for which the tort claim was paid)

Patient’s age at time of incident:________________ Patient’s gender_____________

Date, presenting issue, location of care, name and specialty of licensed practitioner (for example: “on _________ presented to the [ER, neurology clinic, primary care clinic, etc.] with a complaint of …. and was seen by __________________________[also note if this was a trainee])

Provide a detailed summary of the episode of care. Include dates [times if pertinent], locations of care, specialty(s) involved, and practitioners’ names. Include physical exam findings, follow-ups, pertinent labs and tests ordered, and results. If the episode occurred across time, please include the above information for each of the pertinent dates/events.

Do NOT include an evaluation of care in this section. Do NOT include practitioner statement information.

Only the facts of the case per the medical record or other non-protect review materials such as an Administrative Board of Investigations report.

[Insert page break after this section]

CPP Evaluation of Care (1-2 pages) (includes assessment of additional information/statements)

Restatement of Allegation:

Was the standard of care provided?

Note: If substandard care was provided and if the CPP feels this to be a systems issue – it is STILL substandard care and should be noted as such. The RP discussion will eventuate in a determination of substandard care and if it was on the part of a licensed practitioner(s) or a system issue. This is determined by comparing the national standard of care in effect at the time of the incident. It is NOT based on the perception presented in the practitioner statements nor a deviance of care that a CPP may perceive to be normal VA care limitations.

If the standard of care was not provided, is this attributable to the actions of a license’s practitioner?

• Is the identified practitioner a trainee or resident, if so provide the name of supervising physician.

• Have all identified practitioners (including physician supervisors when indicated) been given an opportunity to provide a statement?

• Are there extenuating circumstances to be considered? (address those listed in the statement of the practitioner identified as providing substandard care)

• Is an additional review of care by another specialty recommended?

Rational for the determination: fully expand the rationale for this determination, indicating by name the practitioner(s) associated with the specific actions that fell below the standard of care.

Pertinent Citations