ECHO Case Review Template Submission

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.

• ECHO
• Case Review
• HIPAA Compliance
• Structured Template
• Feedback

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Uploaded on Jul 11, 2024 | 0 Views

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1. 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

2. Case Presenter s name: Name of clinic/agency/institution:

3. Case: Background information Patient s age: Diagnosis: Treatment plan: Geographic location/region: Psychosocial/spiritual/ethical considerations: Other:

4. 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

5. Barriers Ex. lack of resources

6. 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