RANDOM CASE REVIEW FORM

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1 RANDOM CASE REVIEW FORM Period I January 1 to June 30 Period II July 1 to December 31 Period: Year: Reviewing Physician: Date: Medical License Number: FACILITY INFORMATION Name: Operating Surgeon: Total Number of Cases for this Period: PATIENT INFORMATION Patient Initials: Gender: Height: Age: Weight: Ethnicity: SURGICAL CASE INFORMATION Date: Duration: hours minutes Procedure: NOTE: If there were additional procedures, please list them below Procedure # 2: Procedure # 3: ANESTHESIA INFORMATION Type of Anesthesia: Anesthesia Provider (Anesthesiologist, CRNA, Operating Surgeon with Nurse): Anesthesia Duration: hours minutes CHART REVIEW 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

were additional procedures, please list them below Procedure # 2: Procedure # 3: ANESTHESIA INFORMATION Type of Anesthesia: Anesthesia Provider (Anesthesiologist, CRNA, Operating Surgeon with Nurse):

UNANTICIPATED SEQUELA FORM Period I January 1 to June 30 Period II July 1 to December 31 Period: Year: Reviewing Physician s Name: Medical License Number: Review Date: FACILITY INFORMATION Name:

2 UNANTICIPATED SEQUELA FORM Period I January 1 to June 30 Period II July 1 to December 31 Period: Year: Reviewing Physician s Name: Medical License Number: Review Date: FACILITY INFORMATION Name: Operating Physician: PATIENT INFORMATION Patient Initials: Gender: Height: Weight: Age: Ethnicity: SURGERY INFORMATION Original Surgery Date: Duration: Hours Minute SEQUELA INFORMATION 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 INFORMATION 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.

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

3 UNANTICIPATED SEQUELA ADDENDUM SHEET Period I January 1 to June 30 Period II July 1 to December 31 LIPOSUCTION 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: % Marcaine Used: % Amount: per 1000 Infusion Fluid Amount: per 1000 Infusion Fluid HOSPITAL INFORMATION Hospital Name: Date of Admission: Date of Discharge: Reason of Admission: Explanation if Hospital Course (leave blank if not applicable): INFECTION INFORMATION Anatomic Location: Culture Result: Wound Management: Other Therapy:

Used: % Amount: per 1000 Infusion Fluid Amount: per 1000 Infusion Fluid HOSPITAL INFORMATION Hospital Name: Date of Admission: Date of Discharge: Reason of

5 ACCREDITATION OFFICE: 5101 Washington Street, Suite 2F P.O. Box 9500, Gurnee, Illinois Toll Free Phone Phone Fax Web Site: 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 How to Enter Peer Review Enter the AAAASF Website at 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. Page 1 of 2 Continued on back

org 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.

6 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 $ 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 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 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 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 ed to PeerReview@aaaasf.org or faxed to 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. Page 2 of 2

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?

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