IDHI Stroke Program QI/Peer Review Case Summary

Reporting Facility or Agency:

Date of Occurrence:

Patient Name:

First Last

Patient Outcome:

Case Review Date:

Stroke Band Number:

Determination:

Other:

Was the event preventable?

Explain:

Were Opportunities for Improvement (OFI’s) identified? (List)

Quality Improvement Actions:

Please specify education:

Corrective Action Plan (if needed):

Re-evaluation Date:

Loop Closure Date:

Calendar