Effective Date: 
Fri, 06/08/2007
Mon, 02/05/2018
Mon, 02/05/2018

Peer Review is an integral component of the Quality Management and Improvement Program and shall be conducted on a regular and ongoing basis by CAPS psychiatry staff.
Purpose of Peer Review:

  • Monitoring of indicators of clinical quality and conformity with UCSC CAPS Psychiatry Service and community standards of care. The focus of the review will include completeness of documentation, diagnostic assessments, and medication management.
  • Identifying opportunities for improvement in clinical care and providing feedback and educational opportunity for staff psychiatrists and nurse practitioners.
  • Providing information to the Director of Psychiatry, CAPS Director, and SHC Medical Director as one component of the clinical credentialing, privileging, and evaluation process.



It is the responsibility of the Director of Psychiatriy, with the advice and consultation of the psychiatric and medical staff, to identify and address any problems or opportunities for improvement in the clinical care provided by members of the CAPS psychiatric staff.
1. Twice yearly, during the academic term, 5 charts of each clinician (psychiatrist or psychiatric nurse practitioner) will be randomly distributed to the other clinicians on the psychiatry staff for peer review. The reviewers will use a peer review form (see attached) to evaluate whether, in their judgment, clinical care and documentation met UCSC CAPS Psychiatry Service and community standards of care.
2. Charts will be reviewed in the electronic medical record.
3. In cases where the peer reviewer feels the care deviates significantly from the community and UCSC CAPS Psychiatry Service standards, the reviewer will indicate that further review is required.
4. Cases requiring further review will be reviewed a second time:

  • By the Director of Psychiatry, if the Director of Psychiatry was neither the first reviewer nor the psychiatrist under review.
  • By another staff psychiatrist or psychiatric nurse practitioner, if the Director of Psychiatry was the first reviewer or the psychiatrist under review. The second reviewer may request additional information on the care of the case from the treating psychiatrist. If the second reviewer also states that the management of the case was inadequate, the issue will be forwarded to the Director of Psychiatry who will consult with CAPS management staff. If the Director of Psychiatry is under review, the issue will be forwarded to the CAPS Director, who will consult with the SHC Medical Director as needed. If the second reviewer states the care was adequate, both reviewers’ opinions will be included in a summary sheet, but no further action will be taken.

5. Psychiatrists and psychiatric nurse practitioners will receive a summary sheet detailing results of peer review, including results of second reviews, within thirty days of review. Any psychiatrist or psychiatric nurse practitioner disagreeing with or having concerns about a case review may respond directly or in writing to the Director of Psychiatry and/or the CAPS Director, who will make a written reply.
6. The Quality Management Committee will regularly receive a summary report on Peer Review of psychiatric staff. The Director of Psychiatry will regularly summarize peer review activities in psychiatry to the rest of the Quality Management Committee.
7. A CAPS administrative assistant will designate charts for review for each psychiatrist or psychiatric nurse practitioner by randomly selecting cases new to CAPS Psychiatry in the EMR from the two previous academic quarters under review. Documents to be reviewed will include clinical records, starting with the initial contact and going forward in the academic quarter under review. The CAPS administrative assistant, under the direction of the Director of Psychiatry, will collate the reviews and produce a summary sheet detailing results of peer review for each clinician reviewed.
8. If necessary, training will be provided to the psychiatric staff on general themes and issues that arise from the peer review process.  Peer Review is an integral component of the Quality Management and Improvement program, and shall be conducted on a regular and ongoing basis by CAPS psychiatric staff.

University of California, Santa Cruz                                      CAPS  Psychiatry Service
                                       PSYCHIATRY PEER REVIEW FORM 
Review Date ___________       Staff reviewed ______________  _____________________      Reviewer ____________________
SID# ______________________  Patient Name _______________________________
       Each item is rated 1 for Satisfactory or 0 for Needs Attention. Use NA for items that are Not Applicable. 
                    1.   INTAKE SCORE COMMENTS
1. Current condition 
2. Past History 
3. Mental status examination 
4. Assessment, including 
5. DSM-5 diagnosis 
6. Plan, including medication prescribed 
7. Patient Education, consent, disposition 
                    2. PROGRESS NOTE:   Visits:  Number _____  From: _______________  To: ______________
8. Evaluating and handling major risks, e.g. suicide 
9. Choices of medication(s) and doses of medication(s), including when to change 
10. Monitoring of medication effects and side effects; relevant lab tests 
11. Ongoing clarification of diagnosis 
12. Attention to medical conditions and interactions with medical provider(s) 
13. Referral to and interactions with therapist(s) 
14. Interaction with outside individuals and agencies, e.g. college, family 
15. Ongoing education of patient 
16. Overall handling of case 
              3.  GENERAL  
17. Notes and lab studies dated, signed within the time frame consistent with CAPS policy for documentation of clinical care, and legible 
18. Notes are organized, focused, informative 
19. Is further review indicated? (Y/N)