NURSING PEER REVIEW COMMITTEE: Team Review

The Team Review Template is used for team discussion to review the case and rate nursing standard of care/practice issues, nursing documentation, and overall nursing care. The template is used to document issues identified, follow-up, unit action plan, and meeting attendance.

Nursing Unit: ______Date of Event:Month, Day, Year Date of Nursing Peer Review:Month, Day, Year

Review Team Leader: Nursing Peer Review Coordinator

Team Members: Nurses directly involved in the event, nurses on the unit that were not involved in the event, nurses not involved in the event on a “like” unit that would take care of similar patients, Staff involved in the event that would insight into the event

Description of Event:A brief summary of the patient case/concern is noted in this section.

Nursing Standard of Care/Practice Issues (indicate all that apply)This section we discuss whether there are deviations in nursing judgments and errors in policy-if this a discipline issue it is not a nursing peer review
1 / No issues identified (Care was appropriate)
2 / Knowledge (Can you identify lack of knowledge regarding standard of care or practice?)
3 / Critical Thinking Skills/Gaps (Is there evidence that suggests gaps or lack of critical thinking skills.)
4 / Assessment (Are patient assessments thorough and accurately documented?)
5 / Interventions (Were interventions and/or precautions implemented appropriately based on assessment findings?)
6 / Technique/skills (Were proper techniques and/or skills demonstrated?)
7 / Communication (Evaluate communication between nurses, interdisciplinary and with patient/family)
8 / Planning (Is nursing plan of care appropriate/customized to patient needs? Was care coordinated?)
9 / Follow-up/follow-through (Assessments, issues, orders, etc.)
10 / Policy Compliance (Are policies in place adequate and were they followed?)
11 / Supervision (Was care delegated appropriately? Was staff supervised appropriately?)
12 / Other:
Nursing Documentation(indicate all that apply)This section discusses any documentation issues- i.e., does the documentation reflect what happened to the patient?
1 / No issues with nursing documentation
2 / Documentation does not substantiate clinical course and treatment
3 / Documentation not timely to communicate with other caregivers
4 / Documentation unreadable
5 / Other:
Overall, Nursing Care (select one)Did the nursing care meet standards? Note- things may go wrong and nurses can still meet standards of care
1 / Appropriate (No nursing practice issues identified)
2 / Controversial
3 / Inappropriate

Brief description of nursing standard of care/practice issues:

Brief description of nursing documentation issues:

Follow-up: Is stafffollow-up interview/clarification needed to complete the case review?  YesNo

Staff Member / Committee Member Accountable / Method of Follow-Up
(i.e. Verbal Discussion, Letter, E-Mail,
Attendance at a 2ndCommittee Review)

Exemplary nominations:(attach additional documentation for more than 1)an employee may have behaved exemplary;information would be noted in this section.

Name: Standard of Care/Nursing Practice:

Brief description:

Identification of Issues: This is where we identify what we need to do about the issues identified

 Potential nursing care issue (specific to individual or unit)

 Potential issues outside of unit scope of practice(may be related to processes/systems, or other disciplines or departments)

Issue description(Please include department and/or specific personnel):

Check Actions / Unit Action Plan / Person Accountable / Date Due / Date Complete
No action warranted
Employee self-acknowledged action plan sufficient
Educational letter to employee sufficient
Employee to develop unit staff education (i.e. in service, storyboard, etc.) Specify:
Discussion of informal improvement plan with employee
Formal employee improvement plan with monitoring
Referral to nurse manager for employee follow-up
Referral to nursing leadership for follow-up of issues outside unit scope of practice
Required / Staff Communication Plan (i.e. Huddles, Staff Meetings, Education, etc.) Specify:
Formal staff improvement plan with monitoring (PI Project)
Specify:
Other:
Name/Title / Reviewed / Final Review
(action plan completed)
Team Leader:
Unit Manager:
Director:
CNO:
Other:

Additional Comments or Issues:

CONFIDENTIAL: Peer Review Protected Pursuant to GA Law

This document is not a part of the patient’s permanent record and should be submitted to nursing leadership