Please take a moment to complete this form. 1 Select the reporting period for the case on which you are reporting January, February, March April, May, June July, August, September October, November, December 2 Summarize the case history for one of the cases presented. (Exclude patient identifiers) 3 Purpose for case presentation (please check all that apply) General information Diagnostic evaluation Screening for disease Patient communication or education Safety Treatment planning Reinforce standard of care 4 What did the multidisciplinary team recommend? 5 Why did the multidisciplinary team recommend it? 6 Did the discussion/evaluation/recommendation change the direction or outcome of the case or future cases? No, but this was a good teaching case to reinforce the standard of care Yes it did change practice 7 If you answered yes above, please explain how and why a change was made. Leave this field blank
