| 1 | English French Notes Complete/Exclude
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| 2 | Y / N
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| 3 | CLINICAL REVIEW WORKSHEET (PART 1)
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| 4 | OCCURRENCE:
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| 5 | WARD/CLINIC- CURRENT:
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| 6 | CLINICAL REVIEWER:
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| 7 | REVIEW DATE: ______________
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| 8 | RESIDENT/PROVIDER:
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| 9 | ATTENDING:
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| 10 | Instructions: Review the medical record and answer the following by circling
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| 11 | the appropriate 'Y' or 'N'. Record any comments at the end of the worksheet.
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| 12 | REASON(S) FOR EXCEPTION
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| 13 | PRIMARY REASON CLIN REFERRAL
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| 14 | ACTION(S)
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| 15 | DATE REVIEW COMPLETED:
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| 16 | Should the care in this case be considered for educational presentations
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| 17 | because it was exemplary? ___ YES, ___ NO. If YES, describe.
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| 18 | CONFIRMED ISSUE
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| 19 | Include reviews that were completed after the due date
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| 20 | Enter Y(es) to include those peer and management reviews that
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| 21 | were done, but were completed after the due dates.
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| 22 | Enter N(o) to include only those reviews requested, but not
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| 23 | yet completed.
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| 24 | Delinquent reviews report
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| 25 | DELINQUENT REVIEWS
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| 26 | PEER:
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| 27 | MANAGEMENT:
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| 28 | DUE DATE
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| 29 | REVIEW WORKSHEET
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| 30 | SCREEN:
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| 31 | CLIN REV
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| 32 | PEER REV
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| 33 | MGMT REV
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| 34 | CMTE REV
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| 35 | VAL/CONF
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| 36 | REVW DT:
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| 37 | WARD:
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| 38 | TR SPEC:
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| 39 | MED TM:
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| 40 | ATTEND:
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| 41 | RES/PRV:
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| 42 | ADM DATE:
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| 43 | ADM DXS:
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| 44 | ADM WARD:
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| 45 | CUR WRD:
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| 46 | ORG SRV:
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| 47 | AUTOPSY REQUESTED ( Y / N )
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| 48 | PERFORMED ( Y / N ) CIRCLE 'Y' OR 'N'
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| 49 | Occurrence Screen Patient Inquire
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| 50 | Enter the desired sorting method.
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| 51 | Attending & resident/provider report
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| 52 | PRACTITIONER CODE LIST
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| 53 | CODE NUMBER
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| 54 | If quality of care is rated as level 2 or 3, indicate involved practitioner(s).
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| 55 | SEVERITY OF OUTCOME
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| 56 | Can steps be taken to improve the care of similar patients in the future?
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| 57 | ___ YES, ___ NO. If YES, describe. (Please answer even if quality of
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| 58 | care was rated as
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| 59 | LEVEL 1
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| 60 | Select the date range that the occurrences will be chosen from.
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| 61 | Select screens to include
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| 62 | 1 National screens
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| 63 | 2 Local screens
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| 64 | 3 Inactive screens
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| 65 | Choose any combination of the above, e.g., 1, 1-3, etc.
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| 66 | Select number of occurrences to capture:
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| 67 | Enter the number of occurrences to be printed out
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| 68 | for the inter-reviewer reliability assessment study.
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| 69 | Include blank worksheets
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| 70 | Answer Y(es) to print blank worksheets in addition to the
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| 71 | worksheets that are printed with data from the previous
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| 72 | reviews. Answer N(o) to skip printing of blank worksheets.
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| 73 | Inter-reviewer reliability assessment report
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| 74 | Inter-Reviewer Reliability Assessment Worksheets
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| 75 | (Blank worksheets
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| 76 | for CLINICAL and PEER reviewers for the
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| 77 | Per-centage (=Sel/Tot)
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| 78 | Clinical Reviews
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| 79 | Peer Reviews
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| 80 | Select screen criteria to include
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| 81 | Select any combination of the codes listed above, e.g. 1-3, 1,2
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| 82 | NOTE: This is a 132 column report.
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| 83 | *** Please choose a 132 column output device !! ***
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| 84 | Occurrence Screen Review Summary Report
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| 85 | TOTAL NUMBER OF OCCURRENCES:
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| 86 | 1 - TOTAL RECORDS
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| 87 | SEVERITY OF OUTCOME:
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| 88 | CLINICAL REVIEWS:
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| 89 | PEER REVIEWS:
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| 90 | MANAGEMENT REVIEWS:
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| 91 | COMMITTEE REVIEWS:
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| 92 | OCCURRENCE SCREEN STATISTICAL REVIEW SUMMARY:
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| 93 | REHAB-MED
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| 94 | Print PART II of the Summary of Occurrence Screening
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| 95 | Print a list of all PENDING occurrences
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| 96 | Semi-Annually
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| 97 | Occurrence Screen Semi-Annual Report
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| 98 | SUMMARY OF OCCURRENCE SCREENING - SEMI-ANNUAL REPORT - PART I
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| 99 | (LOCAL SCREENS)
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| 100 | (INACTIVE SCREENS)
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| 101 | MEDICAL CENTER:
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| 102 | PERSON PREPARING REPORT:
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| 103 | TITLE & CORRESPONDENCE SYMBOL OF THE ABOVE:
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| 104 | FTS TELEPHONE:
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| 105 | |CRITERION|--# OF OCCURRENCES---|--OUTCOME OF PEER REVIEW---|-# OF OCCURRENCES-|
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| 106 | | SCREEN | REVIEWED REFERRED |LEVEL LEVEL LEVEL PENDING| REFERRED FOR |
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| 107 | | | CLINICALLY TO PEER | 1 2 3 | SYSTEM EQUIPMENT|
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| 108 | PART II. Information on Program Operation
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| 109 | 2. Improvement Actions
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| 110 | Indicate the types of improvement actions resulting from data collected
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| 111 | through the Occurrence Screening Program during the reporting period.
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| 112 | Type of Action Number of times taken
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| 113 | Discussion of case at service staff meeting
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| 114 | Discussion of case at M&M conference
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| 115 | Service education program
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| 116 | Facility education program
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| 117 | Discussion of case with practitioner by supervisor
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| 118 | Formal counseling of practitioner by supervisor
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| 119 | Investigation or focused study of case
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| 120 | Investigation to review privileges
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| 121 | Other disciplinary action
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| 122 | Changes in policy or procedures
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| 123 | Repair of malfunctioning equipment
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| 124 | Change in ordering of medical supplies or equipment
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| 125 | Development of improved communication procedures
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| 126 | Further study of issues raised by occurrence screening
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| 127 | 3. Results of the Reliability Assessments (Complete only for second report
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| 128 | of fiscal year.)
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| 129 | a. Clinical Review
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| 130 | (1) Date reliability assessment completed ____________________
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| 131 | (2) Percentage agreement found ____________________
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| 132 | b. Peer Review
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| 133 | 4. Service-Specific Occurrences
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| 134 | | (Including Neurology) | | | | |
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| 135 | |
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| 136 | Include only occurrences in this table, i.e., cases requiring clinical review
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| 137 | to determine if further review is necessary. Cases meeting exceptions, are
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| 138 | not included.
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| 139 | Use the following rules in determining the service to which an
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| 140 | occurrence belongs:
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| 141 | Criterion 1 - Service at time of discharge from first hospitalization
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| 142 | Criterion 2 - No rule necessary since only total figure needed
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| 143 | Criterion 3 - No rule necessary since all occurrences are in surgery
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| 144 | Criterion 4 - Service providing care at time of death
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| 145 | column should be used for occurrences belonging to Intermediate
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| 146 | Medicine, Nursing Home Care Unit, Rehabilitation Medicine, SCI, and Domiciliary.
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| 147 | ** The numbers in the
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| 148 | columns should be the same as those in column 1
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| 149 | of Part I if all occurrences were clinically reviewed.
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| 150 | 5. Facility Workload Data (Should be readily available from Medical
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| 151 | Administration Service)
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| 152 | a. Number of Admissions to Acute Care during Reporting Period:
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| 153 | Reference : RCS 10-0021 (8ZD1) VA Inpatient Care
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| 154 | Under the
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| 155 | Gains
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| 156 | Total - Adm & Trans
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| 157 | List for each Bed Section:
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| 158 | Medicine (Include Neurology, exclude Intermediate Med.)
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| 159 | b. Number of
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| 160 | Ambulatory Care
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| 161 | Visits During Reporting Period
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| 162 | Reference: RCS 10-0004 (BPA1) Outpatient Health Service Workload
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| 163 | Purpose of Visit
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| 164 | Unscheduled Visits
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| 165 | c. Number of Surgical Procedures Performed
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| 166 | Reference: VA Form 10-7396d Annual Report of Surgical Procedures
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| 167 | Sum the Total Reported at the Bottom of each Part that is compiled
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| 168 | for each Surgical Section.
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| 169 | NOTE: The reports cited for the first two items are cumulative. March's
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| 170 | cumulative totals are the data to be reported for the first semi-annual
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| 171 | report of the fiscal year. Data for the second semi-annual report are
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| 172 | derived by subtracting March's figures from September's totals.
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| 173 | No pending occurrences found.
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| 174 | SCREEN:
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| 175 | PENDING OCCURRENCES
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| 176 | Type 1 - Clinical action of 'Refer to Peer Review', but no Peer review was found
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| 177 | Type 2 - Peer review(s) found for service(s), but none are marked as being final
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| 178 | DATE OF OCCURRENCE
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| 179 | Occurrences by service
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| 180 | *** NO OCCURRENCES FOUND IN THE SELECTED DATE RANGE ***
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| 181 | OCCURRENCES BY SERVICE
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| 182 | PATIENT / SCREEN
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| 183 | TREATING SPEC.
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| 184 | Do you want the report sorted by CRITERIA or SERVICE: CRITERIA//
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| 185 | Enter SERVICE to produce a report sorted by Service.
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| 186 | (This option produces a 'table-like' report.)
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| 187 | Enter CRITERIA to produce a report sorted by Screen Criteria.
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| 188 | (This option produces a 'spreadsheet-like' report.)
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| 189 | Occurrence Screen Service Statistics Report
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| 190 | OCCURRENCE SCREEN SERVICE STATISTICS
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| 191 | SERVICE TOTAL
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| 192 | System/equipment problems report
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| 193 | SYSTEM & EQUIP
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| 194 | SYSTEM / EQUIPMENT PROBLEMS
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| 195 | Review level tracking report
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| 196 | REVIEW LEVEL TRACKING
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| 197 | PREVIOUS REVIEWS
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| 198 | Care type
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| 199 | Treating specialty care types report
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| 200 | ?: *** NOT SPECIFIED ***;
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| 201 | TREATING SPECIALTY CARE TYPES
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| 202 | This option purges the historical data that tells the Occurrence Screen
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| 203 | package on what dates auto enrollment was run
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| 204 | QAO SCREEN
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| 205 | *** Beginning date must be in the past !! ***
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| 206 | Purge auto enroll run dates file
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| 207 | Current Ward/Clinic
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| 208 | Patients awaiting clinical review
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| 209 | NO PATIENTS FOUND AWAITING CLINICAL REVIEW
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| 210 | PATIENTS AWAITING CLINICAL REVIEW
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| 211 | CURR/OCCUR
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| 212 | OCCUR/CURR
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| 213 | AUTO ENROLLED OCCURRENCE
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| 214 | Occurrence Screen auto enroll output
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| 215 | No patients found meeting this screen.
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| 216 | Number of occurrences:
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| 217 | AUTO ENROLLED OCCURRENCE SCREEN PATIENTS
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| 218 | OCCURRENCE DATE:
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| 219 | (* Denotes that this occurrence has already been entered into the system)
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| 220 | Previous Movement
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| 221 | of fiscal year.)
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| 222 | Enter an exact date (month, day, and year) less than or equal to today
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| 223 | Enter a number from 0 to 100, two decimal places allowed, no '%'
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| 224 | (2) Percentage agreement found:
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| 225 | Administration Service)
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| 226 | Under the
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| 227 | List for each Bed Section:
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| 228 | Enter a number from 0 to 99999
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| 229 | and Line D
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| 230 | Visits During Reporting Period:
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| 231 | Sum the Total Reported at the Bottom of each Part that is compiled
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| 232 | for each Surgical Section.
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| 233 | NOTE: The reports cited for Medicine, Surgery, Psychiatry, and Ambulatory Care
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| 234 | are cumulative. March's cumulative totals are the data to be reported for the
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| 235 | first semi-annual report of the fiscal year. Data for the second semi-annual
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| 236 | report are derived by subtracting March's figures from September's totals.
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| 237 | SUMMARY OF OCCURRENCE SCREEN
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| 238 | QAOSUPLD(
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| 239 | Results of Reliability Assessments.
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| 240 | Date clinical review reliability assessment completed:
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| 241 | Percentage agreement found:
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| 242 | Date peer review reliability assessment completed:
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| 243 | Facility Workload Data.
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| 244 | Number of admissions to acute care by bed section.
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| 245 | Medicine (Include Neurology, exclude Intermediate Med.):
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| 246 | Surgery:
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| 247 | Psychiatry:
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| 248 | ambulatory care visits:
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| 249 | Number of surgical procedures performed:
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| 250 | WARNING: This data will overwrite your pre-existing data
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| 251 | at the NQADB for this semi-annual period !!
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| 252 | Ready to send the
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| 253 | data to the National Quality
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| 254 | Assurance DataBase (NQADB) at
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| 255 | Please answer Y(es) or N(o)
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| 256 | Select Worksheet Type(s)
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| 257 | Select the type(s) of worksheet(s) you want printed, e.g., 1,2 or 1-4
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| 258 | 1 Clinical worksheet
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| 259 | 2 Peer worksheet
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| 260 | 3 Management worksheet
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| 261 | 4 Committee worksheet
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| 262 | How do you want the worksheet(s) printed
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| 263 | Enter 1 to print the worksheet(s) for selected patient(s), or
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| 264 | Enter 2 to print the worksheet(s) for a range of dates, or
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| 265 | Enter 3 to print completely blank worksheets.
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| 266 | Enter 1 to print blank worksheets, or
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| 267 | Enter 2 to print worksheets for reviews currently in process/complete
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| 268 | PRINT OCCURRENCE SCREEN WORKSHEETS
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| 269 | How many copies of each worksheet do you want:
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| 270 | Enter the number of copies of each worksheet you want printed.
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| 271 | Your answer must be from 1 to 10.
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| 272 | Another one:
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| 273 | Select a patient by name or SSN. To deselect a patient type a minus (-)
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| 274 | sign and the patient name or SSN, e.g. -DOE,JOHN
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| 275 | YOU HAVE ALREADY SELECTED:
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| 276 | OCCURRENCE BEING
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| 277 | REVIEW DUE DATES
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| 278 | NAME :
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| 279 | PEER :
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| 280 | WARD/CLINIC :
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| 281 | MGMT :
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| 282 | DATE :
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| 283 | SCREEN :
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| 284 | Select OPEN, CLOSED, or BOTH types of occurrences? BOTH//
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| 285 | Valid entries are OPEN, CLOSED, BOTH, or Up-Arrow (^) to exit.
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| 286 | Enter OPEN to select occurrences whose status is open.
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| 287 | Enter CLOSED to select occurrences whose status is closed.
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| 288 | Enter BOTH to select both OPEN and CLOSED occurrences.
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| 289 | Enter Up-Arrow (^) to EXIT.
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| 290 | You do not have a division defined.
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| 291 | Your division is incorrect.
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| 292 | Create a New Survey
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| 293 | Survey NAME:
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| 294 | This is not a new survey.
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| 295 | Please use the edit feature for any changes.
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| 296 | Note: The survey description was not entered !
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| 297 | Note: The survey instructions were not entered !
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| 298 | Do you really want to delete this survey
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| 299 | If you answer Y you will have to re-enter the survey information.
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| 300 | If you answer N you will return to editing.
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| 301 | >> Survey deleted <<
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| 302 | Do you wish to edit any of this basic information
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| 303 | #################### #################### ####################
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| 304 | #################### #################### ####################
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| 305 | #################### #################### ####################
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| 306 | #################### #################### ####################
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| 307 | #################### #################### ####################
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