Tidewater Regional Trauma Triage Quality Improvement Referral

Purpose: The purpose of this referral is to improve the quality and efficiency of trauma care in the Tidewater region. The intended use of this document is to identify variances in trauma triage, including trauma patient transport decisions and diversions. The intent of this form is to identify "system" issues. Information obtained will be used by the Trauma Triage Quality Improvement Committee to identify and offer solutions to improve the trauma system as a whole. This referral will not be used as a disciplinary tool. All information obtained will remain confidential.

Your Name:Your Agency:

Your E-Mail Address:

Agency/Facility Targeted for QI*: *EMS Incident #:

Patient Record #:

Receiving Hospital/s:

Date Received at/by Hospital (mm/dd/yy):

Injury/Diagnosis (In your words):

Date of Events (mm/dd/yy): Time of Incident (00:00):

Patient (Name):

Patient SSN#: Patient DOB:

Purpose of the referral:

Patient Care Issue

Disposition/Destination/Referral Issue

Equipment Issue

Other (Please state):

Description of Events (Please explain below):

Pursuant to sections § 8.01-581.16, 8.01-581.17, 32.1-116.2, of the Virginia Codes, data or information in the possession of or transmitted to the Commissioner, the Advisory Board, or any committee acting on behalf of the Advisory Board, any hospital or prehospital care provider, or any other person shall be privileged and shall not be disclosed or obtained by legal discovery proceedings, unless a circuit court, after a hearing and for good cause shown arising from extraordinary circumstances, orders disclosure of such data.