CONFIDENTIALITY - Lurie Children's Hospital



To: Click here to enter text.Date: Click here to enter a date.From: Click here to enter text./ Pediatric Quality Coordinator at Click here to enter text. (Hospital Name)RE: Performance Improvement / Case ReviewWe recently transferred the following patient to your hospital. In order to identify areas for improvement, our emergency department QI program reviews all aspects of care in accordance with our hospital policies as well as the Illinois Department of Public Health’s PCCC/EDAP/SEDP Rules and Regulations. This information will assist our pediatric quality efforts. Please review the following case, provide the requested information, and return this form to: Click here to enter text.. Thank you, Click here to enter text.EMSC Pediatric Quality CoordinatorPatient Name/Initials:Click here to enter text. Date of Transfer: Click here to enter a date.Mode of Transfer: Click here to enter text. Accepting Physician: Click here to enter text.Transferring Diagnosis: Click here to enter text.*****************************************************************************************Plan of Care at Your Hospital: Click here to enter text.Procedures Completed at Your Hospital: Click here to enter text.Discharge Disposition: Click here to enter text. Discharge Date: Click here to enter a date. Social Issues Identified/DCFS Recommendations: Click here to enter text.Performance Improvement Issues Suggested for Review: Click here to enter text.Your Name/Title: Click here to enter text. Date: Click here to enter a date.Your email address: Click here to enter text.ConfidentialityThe purpose of this information is to review, monitor and measure patient care for the purpose of performance improvement. This information is subject to protection under the Illinois Medical Studies Act, as well as other applicable State and Federal laws and regulations. This information may not be copied, disclosed or disseminated to any other person or entity outside of the performance improvement process. ................
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