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