PATIENT CARE MANAGEMENT INDICATOR/OCCURRENCE REVIEW

Admission Diagnosis:_________________________________
MR#:______________ Dism. Date:_______________________
PCC Reviewer:________________________________________
Patient Sticker:






Indicator/Occurrence                    Dept.           Responsible department or
                                                              Staff member
________________________________________________________________________________________________															   
Work-up: Delay or omitted
procedure (i.e. failure 
to order echo, failure 
to give prep, etc.)
________________________________________________________________________________________________
Monitoring: Abnormal patient 
occurrence due to 
insufficient monitoring 
(i.e. unplanned extubation)
________________________________________________________________________________________________
Abnormal Labs: Delay or 
omission  of laboratory
workups (i.e. delay in 
notification of abnormal 
lab results, omitted 
lab orders, etc.)
________________________________________________________________________________________________
Medications: Delay or 
inappropriate medication 
administration (i.e. 
Failure to follow five 
rights of medication 
administration: route, 
dose, drug, time, patient)
________________________________________________________________________________________________
Treatments: Delay or 
inappropriate treatment given 
(i.e. Wound care orders 
not followed, physical 
therapy not initiated or 
delayed, etc.)
________________________________________________________________________________________________
Documentation: Lack of 
documentation (i.e. Dr.'s 
orders, verbal orders, 
pt. education, discharge 
planning, etc.) 
________________________________________________________________________________________________
Other: Any 
system occurrence that 
does not fall into the
other categories listed.

Comments:____________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

SYSTEM REVIEW:
______ Appropriate patient care management (No action required).
______ Acceptable patient care management, opinions may vary among practitioners.

Requires ______ Patient care management: Marginal deviation from standard of care.
Action   ______ Patient care management: Significant deviation from standard of care.

ACTION:
____Discuss with/letter to appropriate nurse/ancillary staff member/physician
____Refer to _____________________________ for second review
COMMENT:_____________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________	

_____________________________________________________________________________________

_____________________________________________________________________________________

Nurse Signature:_____________________________________________________________________
Ancillary staff signature:___________________________________________________________
Physician signature:_________________________________________________________________

Return to Document