RANDOM CASE REVIEW FORM

RANDOM CASE REVIEW FORM

Period I – January 1 to June 30 Period II – July 1 to December 31

Reviewing Physician: ____________________________________ Date: _______________________________

Medical License Number: ________________________________

Name: __________________________________________________________________________________________________

Operating Surgeon: _______________________________________________________________________________________

Total Number of Cases for this Period: ____________

Patient Initials: _______________ Gender: ____________ Height: ____________

Age: _____________ Weight: ____________ Ethnicity: _______________

Date: ______________ Duration: __________hours __________minutes

Procedure: _____________________________________________________________________________________________

NOTE: If there were additional procedures, please list them below

Procedure # 2: __________________________________________________________________________________________

Procedure # 3: __________________________________________________________________________________________

Type of Anesthesia: ___________________________________________________________________

Anesthesia Provider (Anesthesiologist, CRNA, Operating Surgeon with Nurse): _______________________________________

Anesthesia Duration: __________hours __________minutes

Pre-Op Plan for Treatment YES NO N/A

Informed Consent YES NO N/A Medical History YES NO N/A

Physical Examination YES NO N/A

Laboratory Reports YES NO N/A

Post-Op Recovery Record YES NO N/A

Anesthesia Record YES NO N/A

RX Given to Patient YES NO N/A

Pathology Report YES NO N/A

Discharge Instructions YES NO N/A

Operative Report YES NO N/A

Recorded in Log Book YES NO N/A

Period: __________ Year: __________

FACILITY INFORMATION

PATIENT INFORMATION

SURGICAL CASE INFORMATION

ANESTHESIA INFORMATION

CHART REVIEW

UNANTICIPATED SEQUELA FORM

Period I – January 1 to June 30 Period II – July 1 to December 31

Reviewing Physician’s Name: __________________________________

Medical License Number: _____________________________ Review Date: _________________________

Name: _________________________________________________________________________________________________

Operating Physician: _________________________________________________________

Patient Initials: ____________ Gender: __________ Height: __________ Weight: __________

Age: __________ Ethnicity: ________________

Original Surgery Date: ____________ Duration: __________ Hours __________Minute

Sequela Type: ___________________________________________________________________________________________

NOTE: Any death occurring in an accredited facility, or any death occurring within thirty days of a surgical procedure performed in an accredited facility must be reported to the AAAASF office within five business days after the facility is notified, or otherwise becomes aware of that death.

Location of Event (physical location, Example: recovery room, home, etc.): __________________________________________

List the procedure(s) preformed that caused the sequela:

Procedure #1: _______________________________________Procedure #2: ________________________________________

Procedure #3: _______________________________________Procedure #4:________________________________________

Recovery Room Time: ______________ Hours ______________ Minutes

Anesthesia Type: __________________________________________________________

Anesthesia Provider (Anesthesiologist, CRNA Operating Surgeon with Nurse): ________________________________________

Anesthesia Duration: _________hours __________minutes

---

Sequela Outcome: _________________________________________________________________________________________

_________________________________________________________________________________________________________

REQUIRED FOR ALL DEATHS:

Days Elapsed Since Sequela(The number of days from the date of the sequela to the date of death): __________

Cause of Death: ________________________________________________________________________________

Date of Death: ____________________________

If any of the procedures reported for this unanticipated sequela included liposuction, infection of resulted in hospitalization, please fill out the Unanticipated Sequela Addendum sheet.

Period: __________ Year: __________

FACILITY INFORMATION

PATIENT INFORMATION

SURGERY INFORMATION

SEQUELA INFORMATION

ANESTHESIA INFORMATION

UNANTICIPATED SEQUELA ADDENDUM SHEET

Period I – January 1 to June 30 Period II – July 1 to December 31

Total Volume Removed: ____________cc Intravenous Fluid Type: _______________

Total Intravenous Fluid Replaced: ____________________________________cc

Infusion Fluid Type: _______________________ Infusion Fluid Amounts: ____________________________cc Epinephrine Amount: ___________________per 1000 cc Infusion Fluid

Lodicaine Used: ____________% Amount: ______________ per 1000 Infusion Fluid Marcaine Used: ____________% Amount: ______________ per 1000 Infusion Fluid

Hospital Name: _________________________________________________________________________________

Date of Admission: _______________________ Date of Discharge: ______________________________

Reason of Admission: ___________________________________________________________________________

Explanation if Hospital Course (leave blank if not applicable): ___________________________________________

_____________________________________________________________________________________________

Anatomic Location: _______________________________________________________________________________________

Culture Result:

___________________________________________________________________________________________

Wound Management: _____________________________________________________________________________________

Other Therapy: __________________________________________________________________________________________

LIPOSUCTION

HOSPITAL INFORMATION

INFECTION INFORMATION

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Peer Review Instructions Prior to Peer Review Data Entry You Will Need:

 Six completed Random Review Forms for each surgeon in your facility and all completed Unanticipated Sequela Forms.

 Your Facility Director’s User ID and Password

If you are having trouble logging in or have forgotten your User ID & Password contact ASF at 888-545-5222

How to Enter Peer Review

 Enter the AAAASF Website at www.aaaasf.org

 Under "Quick Links" Click on "PEER REVIEW LOGIN."

Login with your Facility Director’s User ID and Password

 Click on the name of your surgery center in bold RED letters.

 At the top of the screen enter the total number of cases that were performed for the entire facility this period and then click the “Edit” button. (Important: We are not looking for the total number of cases being reported, rather we need the total number of cases done for the entire facility this period)

 Scroll down to the middle of the page. To the right of the surgeons’ name that you are reporting for click on “Random Review” to enter a Random Review or “Unanticipated Sequela” to enter an Unanticipated Sequela.

 Once the information is completely filled out click “Submit” at the bottom of the page. A screen will pop-up and ask if you would like to update your record, select “agree” and then click “Random Review” or “Unanticipated Sequela” to continue to enter the next case.

 If you need to leave the screen in the middle of entering a Random Review click “Save”

which will save the Review as a “temporary”. When you are ready to complete that Review click on “Show” to the right of your physician’s name and click on the temporary Review, complete the information and click “Submit”.

Peer Review FAQ’s What is Peer Review?

Peer Review is performed every six months and includes the reporting of 6 Random Cases for each physician and all Unanticipated Operative Sequela using the required AAAASF forms and reporting format. A random sample of the cases for each surgeon must include the first case done by each surgeon each month during the reporting period for a total of six cases, plus all unanticipated sequela.

Continued on back

ACCREDITATION OFFICE: 5101 Washington Street, Suite 2F • P.O. Box 9500, Gurnee, Illinois 60031 • Toll Free 1-888-545-5222 Phone 847-775-1970 Phone 847-775-1970 Fax 847-775-1985 • E-mail: [email protected] • Web Site: www.aaaasf.org

__________________________________________________________________________________

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When does Peer Review need to be reported?

Currently, Peer Review is required to be reported twice a year.

Period I runs from January 1 ^st through June 30th.

You may begin reporting your cases online July 1 ^st . All cases for Period I must be reported online by August 15 ^th . Period II runs from July 1 ^st through December 31st.

You may begin reporting your cases online January 1 ^st . All cases for Period II must be reported online by February 15 ^th .

Do we have to report Peer Review online?

Yes, peer review must be reported on-line. If you do not wish to report your Peer Review online, hard copies may be submitted to the AAAASF office for a processing fee of $100.00 per surgeon.

What is an Unanticipated Operative Sequela?

An Unanticipated Operative Sequela is anything unplanned that occurs within 30 days of a procedure such as (but not limited to) unplanned hospital admission, allergic reaction to medication, incorrect needle or sponge count, patient or family complaint, infection etc….

All Unanticipated Operative Sequelae must be reported when submitting Peer Review.

Where are the Random Review Forms and Unanticipated Sequelae Forms located?

The Random Review Forms and Unanticipated Sequela Forms are available on the AAAASF website homepage at www.aaaasf.org. Click the “Peer Review Forms/Help” link located under "Quick Links" and print.

Where do I find my User ID and Password?

The Facility Director’s User ID and Password should be used to gain access to the website in order to enter Peer Review. If you are having trouble logging in with your User ID and Password or have forgotten your User ID and Password please contact the AAAASF 888-545-5222.

What is a Reviewing Physician?

The reviewing physician is the physician who reviewed the cases for your surgeon. If the Reviewing Physician has never reviewed cases for your surgeon before or if you cannot locate their name in the system, be sure to have their medical license number handy and call the AAAASF office, as they may need to be added to the AAAASF data base. Please contact the AAAASF office at 888-545-5222 to have a reviewing physician added to the database.

IMPORTANT - PLEASE NOTE:

If a surgeon using the facility has done less than six cases during a reporting period, that

information must be reported to the Central Office using the Peer Review Exemption form and all of those surgeon’s cases during that period must be reported. For example, if the surgeon only performed two cases during the period you should review and report those two cases online and notify AAAASF by using the Peer Review Exemption Form that can be accessed on-line or you may use the copy provided for you in your Peer Review Packet. The notifications may be e-mailed to [email protected] or faxed to 847-775-1985 Attn: Peer Review.

Please also review the list of physicians provided and contact the AAAASF if you note

discrepancies of staff physicians immediately as this will effect reporting of Peer Review.