Attachment E - Audit Review Template.pdf

CASE ID

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.

PEER REVIEW FOR QUALITY MANAGEMENT REPORT

Case ID:

Patient Name:

Event date(s) to be reviewed:

Episode of Care:

Practitioner to be reviewed:

Credential:

Specialty:

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.

SPECIFIC QUESTIONS FOR REVIEWER:

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SPECIAL INSTRUCTIONS:

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Attachment E: Audit Review Template

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.

BRIEF CLINICAL SUMMARY/CASE OVERVIEW:

SALIENT FEATURES OF THE CASE:

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COMPONENTS OF CARE:

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

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Choose an item.

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

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Choose an item.

3. Was the management of abnormal test results appropriate?

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Choose an item.

4. Was the correct diagnosis made? If not, what is the diagnosis?

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5. Was the medical treatment appropriate?

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

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

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8. Was the patient monitored adequately?

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

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

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11. Was the medical record documentation timely and complete?

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

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13. Was supervision appropriate?

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14. Do you have additional quality improvement suggestions?

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

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

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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.

ANALYSIS THAT SUPPORTS LEVEL OF CARE:

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CONCLUSIONS/RECOMMENDATIONS:

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REFERENCES, IF APPLICABLE:

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2. Numbered List

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REVIEWER’S CREDENTIAL & SPECIALTY:

All contract reviewers are required to provide an attestation that they are board certified, meet clinical qualification requirements, and have no conflict of interest, prior to being assigned to complete a VHA clinical review.