For help completing this form please call Kathleen Kerr:
476-5136,
e-mail: kathK@email.his.ucsf.edu,
fax: 502-2412
| Physician Sponsor:______ | Department:___________ | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Phone:________________ | Fax:__________________ | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Box:__________________ | E-mail:_______________ | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Care issue addressed: e.g., Anticoagulation in Adults;
Detection, Diagnosis & Treatment of Depression; Management of Cancer
Pain; Management of Minor Head Trauma; Screening for Bladder Cancer; Urinary
Incontinence in Adults
Why is this issue important: e.g., high volume diagnosis, problem prone procedure, high cost procedure, unnecessary practice variation, low patient/provider satisfaction, unnecessary variation in LOS, variation in clinical outcomes. Project goals: what you hope to achive, how a practice guideline might address the above described issues. List or attach any guidelines currently available or in use: e.g., AHCPR, NIH, AMA, ACP, internal policy. |
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| Status of Project: ___ Not Yet Begun ___ In Progress ___ Guideline Completed But Not In use ___ Guideline Completed And In Use If the project has not yet begun, when would you be ready to begin?__________________________ Will your group need assistance with: ___ Group Facilitiation ___ Assembling a multidisciplinary team ___ Data collection/analysis ___ Medical Literature Review ___ Guideline Implementation ___ Other
Do you have experience developing or implementing guidelines: Yes __ No__ If yes, please describe:_______________________________________________________________
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