Healthcare Quality Assurance Review

HEALTHCARE QUALITY ASSURANCE REVIEW

Facility Name:    Department/Unit:

Patient / Record Identifiers

Patient Name:

Date of Birth (MM/DD/YYYY):    Medical Record No.:    Chart/Encounter No.:

Review Details

Reviewer Name:    Title/Role:

Review Date (MM/DD/YYYY):    Review Time:    Type of Review:

Scope, Authority, and Confidentiality

This Quality Assurance Review is performed under the facility quality program and applicable privacy policies. Access to protected health information (PHI) for purposes of quality assessment is authorized by facility policy and applicable law. The reviewer certifies that information obtained during this review will be used exclusively for quality improvement, patient safety, and related administrative purposes, and will be maintained in a confidential manner.

The reviewer documents objective findings, identifies deviations from applicable clinical standards or facility policy, and recommends corrective actions as appropriate. Findings may be forwarded to clinical leadership for action, and may result in changes to processes of care to prevent recurrence.

Checklist — Documentation and Clinical Compliance

For each item, check the appropriate box and provide brief comments where indicated.

Findings, Root Cause, and Corrective Action

Responsible Individual / Department for CAP:    Target Completion Date (MM/DD/YYYY):

Patient Notification and Acknowledgment

Was the patient or legally authorized representative notified of the review and any actions that affect care?    Yes    No

Notification method:    In person    Phone    Mail    Other

Date of notification (MM/DD/YYYY):

Certification by Reviewer

I certify that the information contained in this Quality Assurance Review is accurate to the best of my knowledge, that access to the patient record was authorized for quality assessment purposes, and that all reasonable steps will be taken to preserve confidentiality of protected health information.

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