English	French	Notes	Complete/Exclude
   Y / N			
CLINICAL REVIEW WORKSHEET (PART 1)			
OCCURRENCE: 			
WARD/CLINIC- CURRENT: 			
CLINICAL REVIEWER: 			
REVIEW DATE: ______________			
RESIDENT/PROVIDER: 			
ATTENDING: 			
Instructions: Review the medical record and answer the following by circling			
the appropriate 'Y' or 'N'.  Record any comments at the end of the worksheet.			
REASON(S) FOR EXCEPTION			
PRIMARY REASON CLIN REFERRAL			
ACTION(S)			
DATE REVIEW COMPLETED: 			
Should the care in this case be considered for educational presentations			
because it was exemplary? ___ YES, ___ NO.  If YES, describe.			
CONFIRMED ISSUE			
Include reviews that were completed after the due date			
Enter Y(es) to include those peer and management reviews that			
were done, but were completed after the due dates.			
Enter N(o) to include only those reviews requested, but not			
yet completed.			
Delinquent reviews report			
DELINQUENT REVIEWS			
PEER:			
MANAGEMENT:			
DUE DATE			
 REVIEW WORKSHEET			
SCREEN:   			
CLIN REV			
PEER REV			
MGMT REV			
CMTE REV			
VAL/CONF			
REVW DT: 			
WARD:     			
TR SPEC:  			
MED TM:  			
ATTEND:   			
RES/PRV: 			
ADM DATE: 			
ADM DXS: 			
ADM WARD: 			
CUR WRD: 			
ORG SRV: 			
AUTOPSY REQUESTED ( Y / N )			
PERFORMED ( Y / N )   CIRCLE 'Y' OR 'N'			
Occurrence Screen Patient Inquire			
     Enter the desired sorting method.			
Attending & resident/provider report			
PRACTITIONER CODE LIST			
CODE NUMBER			
If quality of care is rated as level 2 or 3, indicate involved practitioner(s).			
SEVERITY OF OUTCOME			
Can steps be taken to improve the care of similar patients in the future?			
___ YES, ___ NO.  If YES, describe.  (Please answer even if quality of			
care was rated as 			
LEVEL 1			
Select the date range that the occurrences will be chosen from.			
Select screens to include			
  1  National screens			
  2  Local screens			
  3  Inactive screens			
Choose any combination of the above, e.g., 1, 1-3, etc.			
Select number of occurrences to capture: 			
Enter the number of occurrences to be printed out			
for the inter-reviewer reliability assessment study.			
Include blank worksheets			
Answer Y(es) to print blank worksheets in addition to the			
worksheets that are printed with data from the previous			
reviews.  Answer N(o) to skip printing of blank worksheets.			
Inter-reviewer reliability assessment report			
Inter-Reviewer Reliability Assessment Worksheets			
(Blank worksheets 			
for CLINICAL and PEER reviewers for the 			
Per-centage (=Sel/Tot)			
Clinical Reviews			
Peer     Reviews			
Select screen criteria to include			
Select any combination of the codes listed above, e.g. 1-3, 1,2			
NOTE: This is a 132 column report.			
*** Please choose a 132 column output device !! ***			
Occurrence Screen Review Summary Report			
TOTAL NUMBER OF OCCURRENCES: 			
 1 - TOTAL RECORDS			
SEVERITY OF OUTCOME: 			
CLINICAL REVIEWS: 			
PEER REVIEWS: 			
MANAGEMENT REVIEWS: 			
COMMITTEE REVIEWS: 			
OCCURRENCE SCREEN STATISTICAL REVIEW SUMMARY: 			
REHAB-MED			
Print PART II of the Summary of Occurrence Screening			
Print a list of all PENDING occurrences			
Semi-Annually			
Occurrence Screen Semi-Annual Report			
SUMMARY OF OCCURRENCE SCREENING - SEMI-ANNUAL REPORT - PART I			
 (LOCAL SCREENS)			
 (INACTIVE SCREENS)			
MEDICAL CENTER: 			
PERSON PREPARING REPORT: 			
TITLE & CORRESPONDENCE SYMBOL OF THE ABOVE: 			
FTS TELEPHONE: 			
|CRITERION|--# OF OCCURRENCES---|--OUTCOME OF PEER REVIEW---|-# OF OCCURRENCES-|			
| SCREEN  | REVIEWED   REFERRED |LEVEL  LEVEL  LEVEL PENDING|   REFERRED FOR   |			
|         | CLINICALLY  TO PEER |  1      2      3          | SYSTEM  EQUIPMENT|			
PART II.  Information on Program Operation			
2.  Improvement Actions			
Indicate the types of improvement actions resulting from data collected			
through the Occurrence Screening Program during the reporting period.			
     Type of Action                                       Number of times taken			
Discussion of case at service staff meeting			
Discussion of case at M&M conference			
Service education program			
Facility education program			
Discussion of case with practitioner by supervisor			
Formal counseling of practitioner by supervisor			
Investigation or focused study of case			
Investigation to review privileges			
Other disciplinary action			
Changes in policy or procedures			
Repair of malfunctioning equipment			
Change in ordering of medical supplies or equipment			
Development of improved communication procedures			
Further study of issues raised by occurrence screening			
3.  Results of the Reliability Assessments (Complete only for second report			
    of fiscal year.)			
   a.  Clinical Review			
      (1)  Date reliability assessment completed  ____________________			
      (2)  Percentage agreement found             ____________________			
   b.  Peer Review			
4.  Service-Specific Occurrences			
|   (Including Neurology) |             |              |            |          |			
     |    			
Include only occurrences in this table, i.e., cases requiring clinical review			
to determine if further review is necessary.  Cases meeting exceptions, are			
not included.			
Use the following rules in determining the service to which an			
occurrence belongs:			
   Criterion 1 - Service at time of discharge from first hospitalization			
   Criterion 2 - No rule necessary since only total figure needed			
   Criterion 3 - No rule necessary since all occurrences are in surgery			
   Criterion 4 - Service providing care at time of death			
 column should be used for occurrences belonging to Intermediate			
Medicine, Nursing Home Care Unit, Rehabilitation Medicine, SCI, and Domiciliary.			
** The numbers in the 			
 columns should be the same as those in column 1			
of Part I if all occurrences were clinically reviewed.			
5.  Facility Workload Data (Should be readily available from Medical			
    Administration Service)			
   a.  Number of Admissions to Acute Care during Reporting Period:			
Reference : RCS 10-0021 (8ZD1) VA Inpatient Care			
   Under the 			
Gains			
Total - Adm & Trans			
   List for each Bed Section:			
      Medicine (Include Neurology, exclude Intermediate Med.)			
   b.  Number of 			
 Ambulatory Care			
       Visits During Reporting Period			
Reference: RCS 10-0004 (BPA1) Outpatient Health Service Workload			
Purpose of Visit			
Unscheduled Visits			
   c.  Number of Surgical Procedures Performed			
Reference: VA Form 10-7396d Annual Report of Surgical Procedures			
   Sum the Total Reported at the Bottom of each Part that is compiled			
   for each Surgical Section.			
NOTE: The reports cited for the first two items are cumulative.  March's			
cumulative totals are the data to be reported for the first semi-annual			
report of the fiscal year.  Data for the second semi-annual report are			
derived by subtracting March's figures from September's totals.			
No pending occurrences found.			
SCREEN: 			
PENDING OCCURRENCES			
Type 1 - Clinical action of 'Refer to Peer Review', but no Peer review was found			
Type 2 - Peer review(s) found for service(s), but none are marked as being final			
DATE OF OCCURRENCE			
Occurrences by service			
*** NO OCCURRENCES FOUND IN THE SELECTED DATE RANGE ***			
OCCURRENCES BY SERVICE			
PATIENT / SCREEN			
TREATING SPEC.			
Do you want the report sorted by CRITERIA or SERVICE: CRITERIA// 			
Enter SERVICE to produce a report sorted by Service.			
(This option produces a 'table-like' report.)			
Enter CRITERIA to produce a report sorted by Screen Criteria.			
(This option produces a 'spreadsheet-like' report.)			
Occurrence Screen Service Statistics Report			
OCCURRENCE SCREEN SERVICE STATISTICS			
SERVICE TOTAL			
System/equipment problems report			
SYSTEM & EQUIP			
SYSTEM / EQUIPMENT PROBLEMS			
Review level tracking report			
REVIEW LEVEL TRACKING 			
  PREVIOUS REVIEWS			
Care type			
Treating specialty care types report			
?: *** NOT SPECIFIED ***;			
TREATING SPECIALTY CARE TYPES			
This option purges the historical data that tells the Occurrence Screen			
package on what dates auto enrollment was run			
QAO SCREEN			
*** Beginning date must be in the past !! ***			
Purge auto enroll run dates file			
Current Ward/Clinic			
Patients awaiting clinical review			
NO PATIENTS FOUND AWAITING CLINICAL REVIEW			
PATIENTS AWAITING CLINICAL REVIEW			
CURR/OCCUR			
OCCUR/CURR			
AUTO ENROLLED OCCURRENCE			
Occurrence Screen auto enroll output			
No patients found meeting this screen.			
Number of occurrences: 			
AUTO ENROLLED OCCURRENCE SCREEN PATIENTS			
OCCURRENCE DATE: 			
   (* Denotes that this occurrence has already been entered into the system)			
Previous Movement			
of fiscal year.)			
Enter an exact date (month, day, and year) less than or equal to today			
Enter a number from 0 to 100, two decimal places allowed, no '%'			
      (2)  Percentage agreement found: 			
Administration Service)			
  Under the 			
  List for each Bed Section:			
Enter a number from 0 to 99999			
 and Line D			
Visits During Reporting Period: 			
  Sum the Total Reported at the Bottom of each Part that is compiled			
  for each Surgical Section.			
NOTE: The reports cited for Medicine, Surgery, Psychiatry, and Ambulatory Care			
are cumulative.  March's cumulative totals are the data to be reported for the			
first semi-annual report of the fiscal year.  Data for the second semi-annual			
report are derived by subtracting March's figures from September's totals.			
SUMMARY OF OCCURRENCE SCREEN			
QAOSUPLD(			
Results of Reliability Assessments.			
Date clinical review reliability assessment completed:			
Percentage agreement found:			
Date peer review reliability assessment completed: 			
Facility Workload Data.			
Number of admissions to acute care by bed section.			
Medicine (Include Neurology, exclude Intermediate Med.):			
Surgery:			
Psychiatry:			
 ambulatory care visits:			
Number of surgical procedures performed:			
WARNING: This data will overwrite your pre-existing data			
         at the NQADB for this semi-annual period !!			
Ready to send the 			
 data to the National Quality			
Assurance DataBase (NQADB) at 			
Please answer Y(es) or N(o) 			
Select Worksheet Type(s)			
Select the type(s) of worksheet(s) you want printed, e.g., 1,2 or 1-4			
  1  Clinical worksheet			
  2  Peer worksheet			
  3  Management worksheet			
  4  Committee worksheet			
How do you want the worksheet(s) printed			
Enter 1 to print the worksheet(s) for selected patient(s), or			
Enter 2 to print the worksheet(s) for a range of dates, or			
Enter 3 to print completely blank worksheets.			
Enter 1 to print blank worksheets, or			
Enter 2 to print worksheets for reviews currently in process/complete			
PRINT OCCURRENCE SCREEN WORKSHEETS			
How many copies of each worksheet do you want: 			
Enter the number of copies of each worksheet you want printed.			
Your answer must be from 1 to 10.			
Another one: 			
Select a patient by name or SSN.  To deselect a patient type a minus (-)			
sign and the patient name or SSN, e.g. -DOE,JOHN			
 YOU HAVE ALREADY SELECTED:			
OCCURRENCE BEING 			
REVIEW DUE DATES			
NAME        : 			
PEER : 			
WARD/CLINIC : 			
MGMT : 			
DATE        : 			
SCREEN      : 			
Select OPEN, CLOSED, or BOTH types of occurrences? BOTH// 			
Valid entries are OPEN, CLOSED, BOTH, or Up-Arrow (^) to exit.			
Enter OPEN to select occurrences whose status is open.			
Enter CLOSED to select occurrences whose status is closed.			
Enter BOTH to select both OPEN and CLOSED occurrences.			
Enter Up-Arrow (^) to EXIT.			
You do not have a division defined.			
Your division is incorrect.			
Create a New Survey			
Survey NAME: 			
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Please use the edit feature for any changes.			
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Note:  The survey instructions were not entered !			
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If you answer Y you will have to re-enter the survey information.			
If you answer N you will return to editing.			
>> Survey deleted <<			
Do you wish to edit any of this basic information			
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