Step 3: QI/Peer Review Case Summary This is a privileged and confidential document. The contents shall not be disclosed to any person, agency or entity not directly associated with the hospital peer review or the quality improvement process. Reporting Facility or Agency:Date of Occurrence: MM slash DD slash YYYY Patient Name: First Last Patient Outcome:Case Review Date: MM slash DD slash YYYY Stroke Band Number:Determination: Symptom Related Disease Related Provider Related Other Other:Was the event preventable? Yes No Undetermined Explain:Were Opportunities for Improvement (OFI’s) identified? (List)Quality Improvement Actions: None required Trend Guideline or Protocol implemented Counseling FYI Letter Letter with follow up required Education: Please specify education:Corrective Action Plan (if needed):Re-evaluation Date: MM slash DD slash YYYY Loop Closure Date: MM slash DD slash YYYY
