Medical Case Review Checklist Form
Complete this checklist to ensure all critical aspects of the medical case have been reviewed.
Case Reference Number
*
Type of Case
*
Please Select
Inpatient
Outpatient
Emergency
Consultation
Other
Checklist of Required Documentation
*
Clinical notes present
Lab results attached
Imaging reviewed
Medication list complete
Consent form available
Other
Clinical Findings Summary
*
Diagnosis Confirmed?
*
Yes
No
Uncertain
Severity Assessment
*
1
2
3
4
5
Were all protocols followed?
*
Yes
No
Partially
Checklist: Additional Review Items
Follow-up required
Second opinion needed
Referral recommended
No further action
Reviewer Comments
Submit Review
Should be Empty: