Sample QI Form

(Sample) Telephone Interaction and Documentation QI Process
Month of Review:	CONFIDENTIAL	Documentation (note "+", "-", or "NA")
Patient's Initials
Date of call
Nurse's Initials:
VITAL DATA
Length of call back time
Total length of call (minutes)
Patient's name
Date of birth
Primary physician/MD on call
Telephone number
Medication allergies
Patient's weight
Current medications
SYMPTOMS & ASSESSMENT
History of current illness
Duration of symptoms
Pertinent negatives
Review of systems
Past medical history
DISPOSITION & COMMENTS
Protocol utilized (chief complaint)
Call managed per protocol
Caller understanding
Caller preference
Disposition
MD notified with times
Nursing Assessment
Hospital patient referred to
Insurance/Insurance disclaimer
RN signature
QA CODE
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For any chart with QA code of 4 or 5, copy call record forward to Program Director for secondary review:

1: No disagreements, excellent care	3: Some disagreements, no potential for harm	5: Definite potential for harm
2:No disagreements, adequate care	4: Major disagreements, some potential for harm
Initials of reviewer:______________
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