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"]