May 22, 2003 - Arizona Medical Board



Medical Consultant Report and Summary

Case No: Physician:

Date: Medical Consultant:

1. Detailed (Chronological) Analysis:

2. Proposed Standard(s) of Care:

3. Deviation from the Standard of Care:

4. Actual Harm Identified:

5. Potential Harm Identified:

6. Aggravating Factor(s):

7. Mitigating Factor(s):

8. Consultant’s Summary:

9. Records Reviewed:

______________________________ _______________________

Print Name Date

______________________________

Signature

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download