Peer Reviewer Form
Physician Review Comments
This review is designed to address overall clinical management and/or procedural issues.
Peer Reviewer Assessment – check all that apply
 No issues identified
 Clinical judgment/knowledge error
 Documentation issue (check all that apply)
 Technique/skills
 Does not substantiate clinical course
 Follow up/Follow through
 Not timely to communicate
 Policy Compliance
 Documents unreadable
 Supervision
 Other (describe)
 Communication issue with patient or family
 Diagnosis inappropriate
 Communication/responsiveness to care team
 Diagnosis/Treatment planning untimely/inappropriate
 Other (describe)
choice
Additional Transplant Patient Assessment Only (check all that apply):
 Infection contributing factor to death
 Medical Management
 Immunosuppressive protocol
 Postop ICU Management
 Donor selection
 Recipient selection
 Surgical Management
 Psychosocial factors of patient
Physician Review Outcome
Please check the box next to the most appropriate Standard of Care Level
 0 - Mortality expected; no quality of care issues
 1 - Acceptable medical care
 2 - Acceptable medical care, but complication(s) developed
 3 - Medical care/event which had or could have had an adverse effect on the patient’s well being, but was not lifethreatening
 4 - Medical care which resulted in temporary loss of major physical function of the patient
 5 - Medical care which resulted in a life-threatening situation, permanent loss to the patient of a major physical function or
which resulted in the patient’s death
1.
If you selected a Review Outcome Score of 3 or more, please complete the following questions.
Was the procedure, treatment, or test
 Yes. Complete remaining
 No. Skip to Follow Up
appropriate or warranted for the patient based
questions
Recommendation
on nationally recognized standards?
2.
Was the complication a known risk and was the
standard of care employed to mitigate risk?
 Yes
 No
3.
Was the complication identified in a timely
manner?
Was the complication treated according to the
standard of care and done in a timely manner?
 Yes
 No
 Yes
 No
4.
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Peer Reviewer Form
Peer Reviewer Case Follow Up Recommendation – check all that apply
 No further action necessary
 Practitioner discussion or letter
 Education pertinent to findings
 Further peer review recommended (please identify
practitioner or Department/Division)
 Refer to Department Chair if not already done
 Referral to Physician’s Executive Council
 Referral to Medical Director
 Referral to another department (please specify)
Name of Physician Reviewer: _______________________________________
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Date: _____________