CONFIDENTIAL PEER REVIEW WORKSHEET
FOR USE IN THE QUALITY IMPROVEMENT PROCESS

MRN Admission Date: Incident Date: ___________________

Responsible Attending Physician ____________________ Responsible Resident ________________________

=========================================================================================== REVIEWING PHYSICIAN Review Date:

Outcome

.O-0 No adverse outcome .O-1 Minor adverse outcome (complete recovery expected) .O-2 Major adverse outcome (complete recovery not expected) .O-3 Catastrophic adverse outcome

Physician Care

. C-0 Meets Community Standard (Appropriate)
. C-1 Meets Community Standard (Controversial)
. C-2 Below Community Standard (Inappropriate)
. C-3 Immediate danger – "This case raises concerns of an "immediate danger" if this physician continues to

care for patients. Please directly contact the service chief, medical staff president or hospital CEO."

Physician Documentation

. D-0 No issue with physician documentation . D-1 Documentation unreadable . D-2a Documentation not timely to communicate with other caregivers . D-2b Documentation does not substantiate clinical course and treatment . D-3 Falsification . D-_ Other ______________________________________________

Resident Supervision

. S-0 Adequate . S-1 Inadequate . Not applicable

System Issue

. ___________________________________________

Other Discipline

. ___________________________________________

Rationale/Conclusion:

Please return to Quality Resource Management, CSP-11015 (Ext. 44637)