Step 2: QI/Peer Review Participant Form

Purpose: to establish a method for peer reviews of IDHI Stroke Program consults. This is a privileged and confidential document. The contents shall not be disclosed to any person, agency or entity not directly associated with hospital peer review or IDHI Stroke Program peer review quality improvement process.

IDHI Stroke Program QI Peer/Review Members:

Medical Director- Dr. Sanjeeva Onteddu | UAMS IDHI Clinical Program Director – C. Renee Joiner | UAMS IDHI Stroke Program Director – Lorri Berry | QA Coordinator-Calvin Duncan

Occurrence Site:

Neurologist who conducted the consult:

First Last

Call Center operator who facilitated the call:

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Nurse Facilitator at the site:

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ED Physician at the site:

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Accepting physician at receiving site:

First Last

Lead nurse at receiving site:

First Last

EMS Agency representative (when applicable):

IDHI Stroke Program Outreach Nurse assigned to the region to observe:

First Last

IDHI Stroke Program Video Support :

First Last