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Patient Care Assessment Program
Format for Semi-Annual Report
Name of Facility: ___________________________________
For Six Months Ended: ______________________________
TO:
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Board of Trustees/Governing Body
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FROM:
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Patient Care Assessment Coordinator
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DATE:
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______________________
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cc:
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Massachusetts Board of Registration in Medicine |
I/ We have completed this report to the extent applicable, and have or will have forwarded a copy to the Board of Registration in Medicine within 30 days after the end of the six-month period identified above.
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Major Tasks Completed.
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Summary Report of Internal Incident Reporting Systems.
A. List of focused occurrence reporting criteria and number of incidents identified, by criterion. Format:
| Reporting Criterion |
Number per Month |
| (i) _____________________________ |
___ ___ ___ ___ ___ ___ |
| (ii) ____________________________ |
___ ___ ___ ___ ___ ___ |
| (etc.) __________________________ |
___ ___ ___ ___ ___ ___ |
B. List of occurrence screening criteria and number of criteria triggered as a result of chart review, by criterion. Format:
| Screening Criterion |
# Charts Eligible for Review* |
# Charts Reviewed |
# Occurrences Found |
| (i) _________________________ |
________ |
_______ |
___________ |
| (ii) _________________________ |
________ |
_______ |
___________ |
| (etc.) _______________________ |
________ |
_______ |
___________ |
* A note accompanying these entries should make it clear how the total class of charts eligible for review is defined, with respect to each criterion (e.g., all obstetrical charts; all surgical charts; etc.). In other words, include the denominator.
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Trending and Follow-up.
- Trends observed as a result of internal incident reporting system (including focused occurrence reporting/occurrence screening, and Safety and Quality issues reporting).
- Recommendations for remedial action to be taken, if any, as a result of observations from III.A. above.
- Evaluation of the effects of remedial action taken in III.B. above.
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General Recommendations.
- Recommendations for changes in the PCA program. The source of these recommendations should be identified (e.g., analysis of the internal incident reporting system, peer review activities, other regulatory agencies).
- Other patient care program information (e.g., describe employee training and other educational activity, including that relating to physicians).
- Changes in focused occurrence reporting and occurrence screening criteria.
Submitted by: ______________________________
[Type name and title: __________________________________________________________] |
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