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 review1 / 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? YesNo
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 CompleteNo 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