Dd Form 2526 - Case Abstract For Malpractice Claims Page 3

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15. PROFESSIONAL REVIEW ASSESSMENT BY MEDICAL TREATMENT FACILITY
a. ATTRIBUTION OF CAUSE (X all that apply)
b. EVALUATION OF CARE (X one)
(3) Personnel other
(2) Not Met
(1) Facility or Equipment
(2) Physician
(1) Met
than Physician
(4) Management
(5) System
(3) Indeterminate
c. IDENTIFY LOCATION OF CARE (X one)
(1) Ambulatory
(2) Inpatient
(3) Dental
(4) Emergency
(5) Other (Specify)
Clinic
Clinic
Service
d. INJURY SEVERITY (X one)
e. INJURY DURATION (X one)
(1) None
(2) Some
(3) Death
(1) Temporary
(2) Permanent
(3) Cannot Predict/Undetermined
16. ASSESSMENT
YES
NO (Evaluation of Care. X one)
(1) Met
(2) Not Met
(3) Indeterminate
a. AFIP REQUIRED?
b. OTHER ASSESSMENTS
(1) Met
(2) Not Met
(3) Indeterminate
(1) UCA or Name
(1) Met
(2) Not Met
(3) Indeterminate
(1) UCA or Name
(1) Met
(2) Not Met
(3) Indeterminate
(1) UCA or Name
(1) Met
(2) Not Met
(3) Indeterminate
(1) UCA or Name
c. FINAL OTSG DETERMINATION ACT OR OMISSION CODE(S) (Refer to table on Page 4)
d. CLINICAL SERVICE CODE
(1) Primary Act or Omission Code
(2) Additional Act or Omission Code
(1) Primary
(3) Additional Act or Omission Code
(4) Additional Act or Omission Code
(2) Secondary
(5) Additional Act or Omission Code
(6) Additional Act or Omission Code
(3) Tertiary
MET
YES
17. STANDARD OF CARE (OTSG DETERMINATION)
18. NPDB REPORTED
(X one)
NOT MET
NO
19. REMARKS
DD FORM 2526, FEB 2000
Page 3 of 4 Pages
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