ILLINOIS CRITICAL ACCESS HOSPITAL NETWORK

EXTERNAL PEER REVIEW NETWORK
PROVIDER REPORT FORM

CONFIDENTIAL

Part I – to be completed by the requesting hospital and theICAHN office and sent to the assigned peer review provider’s EPR coordinator.

CHECK TYPE OF REVIEW:____ROUTINE ____EXPEDITED

ROUTINE REVIEWS: 10 business day turnaround time.

EXPEDITED REVIEWS:5 business day turnaround time.(Hospitals may consider expedited reviews for possible/pending litigation, or for credentialing and practitioner evaluation purposes.)

Requesting Hospital Name:
Address:
Requesting EPR Coordinator:
Telephone: / Fax:
Peer Review Request: (family practice, general surgery, obstetrics/gynecology, internal medicine, emergency medicine, orthopedics; anesthesia/pain, pediatric) / Provider Assigned:(ICAHN use)
Provider’sHospital:(ICAHN use)
Send Chart to: / Address:

General Case Description

EPRN Case #(ICAHN Use) / Admission Date:
General Description of the Case:(age, sex, diagnosis, type of case, LOS)
Reason for Case Review:

This report is protected by the Illinois Medical Studies Act. 735ILCS 5/8-2101 ET SEO. (1993)

Part II – to be completed by the peer review providerand returned to the requesting hospital. If dictated, please use this format.

EPRN Case# ______Admission Date ______

 ____Chart incomplete/lacks Provider documentation

If incomplete/lacks documentation, please elaborate below:

______

______

______

______

______

Review Findings ______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

This report is protected by the Illinois Medical Studies Act. 735ILCS 5/8-2101 ET SEO. (1993)

Please evaluate and rate the medical record according to the following scores:

0 – no quality of care issue identified
1 – patient dissatisfaction / perceptual event
2 – clinical practice expected and acceptable
3 – practice may deviate from norm but is acceptable
4– questioned practice / unexpected outcome
5– questioned practice / very unexpected, unfavorable outcome
Please explain reasoning below.
Please evaluate and rate how you, as the reviewing provider, felt about the medical record under review:
0 – 2 Reviewer is comfortable
3 – Reviewer questions practice based on review findings
4– Reviewer disagrees with care based on review findings
Please explain reasoning for adverse findings below.
Please provide any medical literature/evidence based medicine references to support any discrepancies, if applicable.

Provider’s Signature______Date of Review______

1