QUALITY REVIEWED EVENT FORM                                         

**DO NOT MAKE THIS FORM PART OF THE PATIENT'S CHART**

The following incidences MANDATE a report:

  1. Five minute APGAR score of 6.0 or less (cord gases required)
  2. Cord pH less than 7.0
  3. Greater than 24 week fetal demise
  4. Shoulder dystocia with injury
  5. Brachial nerve injury at discharge of patient
  6. Any communication from a legal firm
  7. Unexpected adult death
  8. Brain damage / neurological deficit
  1. Paralysis / nerve injury
  2. Total / partial loss or loss of use of limb(s)
  3. Impairment or loss of sight, hearing, taste, touch or smell
  4. Failure to diagnose resulting in radiation therapy, chemotherapy or other continuous treatment
  5. Surgical complication or return to surgery
  6. NICU Admission after 36 weeks (if greater than 48 hours or transfer to tertiary care facility)

In addition to reporting the mandatory incidences, please disclose any other incidences you feel require reporting

  

This report does not constitute the report of a claim.  A claim is a written request for money or an event that you expect to result in a demand for money.  Claims must be reported on the Claim Submission Form.

Physician Information
   
   
Patient Information
        
  
Event Information
  
*If the QRE covers an extended time period, please enter the LAST date the patient was treated.  Otherwise, please enter the actual date of the event.
If Delivery, complete below:
   

Cord Gas: Required on all delivery related QREs
      
Involved Physician's Comments
    
 
  
Additional Information (Delivery Note, Op Note, additional comments can be uploaded here.  Documents will be sent via secure email to OasisClaims)