ECHO Case Review Template Submission
Instructions to fill out this template
•
All participants must comply with
HIPAA
regulations and
not
use any Patient Identifiers when submitting cases for
review
•
Please briefly describe relevant aspects of your case and
draft your question (s) at the end of the presentation
•
Send this form before the next ECHO session so the
facilitators have some time to review your case and provide
valuable feedback
•
Email your completed form to moliveros@mdanderson.org
Case
Presenter’s name:
Name of clinic/agency/institution:
Case: Background information
•
Patient’s age:
•
Diagnosis:
•
Treatment plan:
•
Geographic location/region:
•
Psychosocial/spiritual/ethical considerations:
•
Other:
Date:
Form of communication(phone, in person, via mail):
Result of encounter:
Date:
Form of communication(phone, in person, via mail):
Result of encounter:
Date:
Form of communication(phone, in person, via mail):
Result of encounter:
* Add additional slides as needed
Case: Interventions (navigation)
Barriers
Ex. lack of resources
Questions/ Discussion
•
Please state your questions for the ECHO Navigation
team
•
Please describe what you would like the team to help
you with (ex. how do we minimize or eliminate the
gap?)
•
Points for discussion
Project ECHO- Cervical Cancer Prevention case template
This template provides structured guidance for participants to submit cases for review at an ECHO session, ensuring compliance with HIPAA regulations. Presenters share relevant case details, interventions, barriers, and questions for the navigation team. Facilitators can provide valuable feedback before the next session, enhancing the learning experience.
Download Presentation
Please find below an Image/Link to download the presentation.
The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author. Download presentation by click this link. If you encounter any issues during the download, it is possible that the publisher has removed the file from their server.
E N D
Presentation Transcript
Instructions to fill out this template All participants must comply with HIPAA regulations and not use any Patient Identifiers when submitting cases for review Please briefly describe relevant aspects of your case and draft your question (s) at the end of the presentation Send this form before the next ECHO session so the facilitators have some time to review your case and provide valuable feedback Email your completed form to moliveros@mdanderson.org
Case Presenter s name: Name of clinic/agency/institution:
Case: Background information Patient s age: Diagnosis: Treatment plan: Geographic location/region: Psychosocial/spiritual/ethical considerations: Other:
Case: Interventions (navigation) Date: Form of communication(phone, in person, via mail): Result of encounter: Date: Form of communication(phone, in person, via mail): Result of encounter: Date: Form of communication(phone, in person, via mail): Result of encounter: * Add additional slides as needed
Barriers Ex. lack of resources
Questions/ Discussion Please state your questions for the ECHO Navigation team Please describe what you would like the team to help you with (ex. how do we minimize or eliminate the gap?) Points for discussion
