ER Provider Concomitant Review Form

General & Administrative
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ER Provider Concomitant Review Form
Visit Date: [date name="visit_date"]
Chart #: [text]
ER Provider: [text]
On-Call Provider: [text]
Patient Presentation Summary: [text]
[select name="complaint_type" value="Chest Pain - Cardiac|Chest Pain - Non-Cardiac|Infection - Localized|Infection - Systemic|Diabetes Related|Alcohol Related|Suicide/Mental Health|Pregnancy|Other"]
[conditional field="complaint_type" condition="(complaint_type).is('Other')"][text name="other_description"][/conditional]
[select name="disposition_type" value="Transfer|Admission"]
Diagnosis: [textarea]
Does an EMC exist based on MSE? [select name="emc" value="Yes|No|N/A|Uncertain"]
Was presentation of the patient complete? [select name="complete_presentation" value="Yes|No"]
[conditional field="complete_presentation" condition="(complete_presentation).is('No')"] What is missing per on-call Attending: [textarea][/conditional]
Was the initial assessment and work up appropriate? [select name="initial_assessment" value="Yes|No|N/A|Uncertain"]
Was the initial treatment plan appropriate? [select name="initial_treatment" value="Yes|No|N/A|Uncertain"]
Were the antibiotics chosen appropriate? [select name="antibiotics" value="Yes|No|N/A|Uncertain"]
Were the ER labs appropriately addressed? [select name="er_labs" value="Yes|No|N/A|Uncertain"]
Were Special Studies ordered and managed appropriately during the ER visit? [select name="special_studies" value="Yes|No|N/A|Uncertain"]
Were Internal / external referrals completed? [select name="referrals" value="Yes|No|N/A|Uncertain"]
Was there clear stabilization of an EMC? [select name="stabilized" value="Yes|No|N/A|Uncertain"]
Were obstacles and hindrances to treatment appropriately addressed with plan for success? [select name="obstacles" value="Yes|No|N/A|Uncertain"]
Were discharge/ admission vitals evaluated? [select name="vitals" value="Yes|No|N/A|Uncertain"]
Was transfer out or admission appropriate? [select name="disposition_ok" value="Yes|No|N/A|Uncertain"]
[conditional field="disposition_type" condition="(disposition_type).is('Admission')"] Were Admission orders appropriately written? [select name="orders_ok" value="Yes|No|Uncertain"][/conditional]
Comments: [textarea]
Issue Identification: [checkbox name="issue_found" value="No issues with provider care|Diagnostic work up|Physical evaluation|Diagnosis|Treatment plan|Judgement|Other"]
[conditional field="issue_found" condition="(issue_found).is('Other')"][textarea name="describe_other"][/conditional]
Comments: [textarea]
Provider Documentation: [checkbox name="provider_documentation" value="No issues|Documentation does not substantiate clinical course and treatment|Documentation not timely to communicate with other caregivers|Documentation is difficult to understand|Documentation inadequate—missing elements"]
[conditional field="provider_documentation" condition="(provider_documentation).isNot('No issues')"][textarea name="describe_documenation_issues"][/conditional]
Recommendation: [select name="recommendation" value="No further action required|Refer to individual provider/physician with suggestions for improvement|Refer to Clinical Director|Referral to Medical Executive Committee"]
Physician Reviewer: [text]
Review Date: [date name="review_date"]
ER Provider Concomitant Review Form
Visit Date:
Chart #:
ER Provider:
On-Call Provider:
Patient Presentation Summary:



Diagnosis:
Does an EMC exist based on MSE?
Was presentation of the patient complete?

Was the initial assessment and work up appropriate?
Was the initial treatment plan appropriate?
Were the antibiotics chosen appropriate?
Were the ER labs appropriately addressed?
Were Special Studies ordered and managed appropriately during the ER visit?
Were Internal / external referrals completed?
Was there clear stabilization of an EMC?
Were obstacles and hindrances to treatment appropriately addressed with plan for success?
Were discharge/ admission vitals evaluated?
Was transfer out or admission appropriate?

Comments:
Issue Identification:

Comments:
Provider Documentation:

Recommendation:
Physician Reviewer:
Review Date:
Result - Copy and paste this output:

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