GUIDELINES FOR CASE ASSESSMENT

Assessor Guidelines

Adverse Event Coding Book (pdf)

Introduction

A case note review is a peer assessment of the death of a patient. It should be carried out in a spirit of sympathetic enquiry and provide sufficient detail for a clear view of events. Points should be made in a detached manner and any opinions expressed should be objective and reasonable. There are advantages to a structured approach and the following guidelines address when to ask for a case note reviews and how the reviews should be carried out.

For 1^st Line Assessors

When to ask for Case Note Reviews

• Where significant errors are thought to have been made by surgeon or anaesthetist
• Where a case note review could usefully draw attention to lessons to be learned, either for clinicians involved in the case or as part of collated assessments
• for wider distribution
• Where there has been an unexpected death (eg in theatre, elective surgery for benign disease, day case surgery, young patients)

• A case note review need not be requested if the adverse events are clear from the audit form and no further information is required
• Indicate on the assessment pro forma why a case note review is being requested

For 2^nd Line Assessors

How to Carry out Case Note Reviews

• Aim for no more than one page of A4
• Choose the most important point to make a "one line message" for an introductory title
• Indicate the patient’s age group (eg young adult, middle aged, elderly)
• Make all patients male with the exception of gynaecological cases
• Omit identifying information eg names, specific dates and locations
• Does the case adhere to a reasonable care pathway. If not, how does it deviate and was it justifiable?

Structure

• Provide a short history and a factual account of the clinical events
• Give constructive comments on what could have been done differently
• Comment on the quality of the record keeping – complete the form below.
• Divide comments into "areas for consideration" (areas requiring further thought by the clinicians involved in the case, possibly reflecting alternative approaches in management) and "areas of concern" (management considered to be sub optimal, preferably supported by literature references). This should result in a focussed assessment with graduated critical comment.
• Suggest changes in practice that could be put in place to avoid repetition of identified adverse events in management, preferably with references.Specifically check the prescription of DVT/PE prophylaxis

• Complete The Surgical/Anaesthetic Assessor’s Pro Forma

Points to remember

• Note any adverse events to allow coding
• Where possible, give references to support your opinion

RECORD KEEPING

Study Number

	Satisfactory	Unsatisfactory	Missing
Medical Admission Note	.	.	.
Medical Follow-up notes	.	.	.
Procedure note/s	.	.	.
Anaesthetic chart/s	.	.	.
Case summary letter to GP	.	.	.

THIS SHEET IS RETURNED WITH THE CASE NOTE REVIEW

June 2000

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