Review a Case - Primary Reviewer
Once you elect to review a case, a new screen with a summary of the case and spaces for you to enter your case review findings will be presented.
The screen consists of five sections which are separated by headings that appear as horizontal blue bars. Two of the sections are hidden – View Case Details and View Case History. Click on a blue bar to reveal the information within the section. Click again to hide the section.
After you finish entering your case findings and review decision you must click on the “Submit” button at the bottom of the screen. If you are not ready to submit your decision, click on the “Save” button at the bottom of the screen so that you do not lose the information you entered.
Patient information is displayed in its entirety and consists of patient identification and demographic data, admission and discharge dates, discharge disposition and attending physician.
This section also includes an indicator (PSRS Match) of whether a patient safety event was previously reported in the voluntary Patient Safety Reporting System (PSRS) for this patient. A value of “Y” for this indicator means that an event was previously reported in PSRS, but may not be the same event as the one summarized on this screen.
This section identifies the event that is the subject of this case review (e.g., Pulmonary Embolism or Deep Vein Thrombosis) and displays the patient’s admit and discharge services and all the services and nursing units on which the patient resided during his/her hospitalization.
This section displays the patient’s principal and secondary diagnoses and principal and secondary procedures. Each diagnosis has a “Present on Admission” (PoA) indicator of whether the diagnosis was present on admission (pre-existing) (PoA = Y) or acquired during the patient’s hospitalization (PoA = N). For some diagnoses, like “Normal Delivery”, it is not meaningful to assign a PoA value; under these circumstances, the diagnosis is exempt (PoA = E).
The diagnosis that caused the event to be flagged for review is highlighted. These are diagnoses that were acquired (PoA = N).
This section displays the review you ultimately complete for this case and all prior reviews and associated comments.
This section provides space for you to enter the findings from your review, including factors that contributed to the occurrence of the event. It also asks you to enter a review decision and final disposition.
After you review the patient’s CareWeb and other records:
1. Enter your answers to the specific questions about your findings. Then, enter additional findings in the text box,
2. From the list of contributing factors, some of which are specific to the type of event and some that are generic and can apply to many types of events, select all that apply. Enter any other contributing factors in the text box.
3. Enter your review decision.
Complication Did Not Occur (Coding Issue) If you determined the case was flagged in error because the ICD-9-CM diagnosis or Present on Admission (PoA) coding was incorrect, provide an explanation in the Findings section, select Review Decision 1 or 2, respectively, and press the Submit button at the bottom of the page to forward the case to Health Information Management.
Complication Occurred: If you determined the complication occurred, provide your rationale in the Findings and Contributing Factors sections and select Review Decision 3 or 4. Then, complete the Final Disposition section and press the Submit button to forward the case to Risk Management.
Case Should be Reassigned: If you determined the case should be reassigned to another reviewer, select Review Decision 5, provide an explanation in the Findings section and press the Submit button to send case to the Administrator for rerouting.
4. Enter the final disposition.
The Final Disposition summarizes your intended action either within your clinical department or within Nursing or instructs the PSI- CRS System Administrator to refer the case to a central unit at the institutional level (e.g., Patient Safety Committee) for follow-up.
If you select a Final Disposition for follow-up action within your Clinical Department or within Nursing, you must take action yourself – the PSI- CRS will not refer the case for you. Under these circumstances, your selection should simply reflect the step(s) you will take (or have taken) to follow up on your findings from this case.
On the other hand, if you recommend follow-up at the Institutional Level, the case will be forwarded for you by the System Administrator.
5. Finally, submit your case findings and review decision by clicking the “Submit” button at the bottom of the screen. (If you are not ready to submit your decision, click on the “Save” button at the bottom of the screen so that you do not lose the information you entered)