GENERAL ONGOING PROFESSIONAL PRACTICE EVALUATION ...

GENERAL ONGOING PROFESSIONAL PRACTICE EVALUATIONName: ____________________________________CONDUCT1. Incident Reports2. Unusual Occurrence Reports3. Staff/Patient/Family ComplaintsComments:Recommendations:MORBIDITY & MORTALITYIncluding:“Never Events” as defined by CMS, BCBSM“Sentinel Events” as defined by TJCMedication Errors□ None requiring review Mortalities reviewed: ______________Resuscitations reviewed: _________ Targeted reviews: _______________________________________________________________□ No adverse outcomes □ Medical management appropriate. Noquality issues_______________________________________________________Minor adverse outcomes: ___ Major adverse outcomes: ___Care appropriate: ___ Care appropriate: _________________________________________________________Medical management controversial: ___Medical management inappropriate: ___Comments:Recommendations:FOCUSED REVIEW/ACTIONIncluding:FPPEPEER ReviewsSuspension/Privilege Restrict______________________________________________________________________________________________________________Comments:Recommendations:PHYSICIAN SIGNATURE:______________________________________________________4