Step 1: Site Case Referral Form | UAMS Stroke Program

Purpose: The purpose of the referral is to improve the quality and efficiency of patient care within the IDHI Stroke Program system in Arkansas. This form is intended to relay both positive and negative comments regarding Stroke Patient Care in the IDHI Stroke Program system of care. Submission of this document triggers further review of a specific incident. All information obtained through this process will remain confidential. This information will be used for improving patient care and will not be used as a punitive tool.

Your Name:

First Last

Your Email:

Patient Name:

First Last

Your Facility/ Agency:

Date of Occurrence:

Initial Treating Site:

Secondary Site (if applicable):

Facility/Agency targeted for QI:

Stroke Band #:

Final Diagnosis:

Patient Outcome:

Purpose of this Referral:

Other explained:

Description of Event(s):

Patient Care Issue
Equipment issue
Call Center issue
Patient transported to inappropriate Facility
Protocol issue
Staff/MD issue
Transfer Delay
EMS issue
Delay of Treatment
Other