Select your state
Choose where the healthcare facility is located
Not legal advice. Terms · Privacy · Disclaimer
Document Preview
PATIENT INCIDENT REPORT
PATIENT INCIDENT REPORT
Report #:
Date Filed:
State:
CONFIDENTIAL — This report contains protected health information subject to HIPAA and should be handled only within authorized healthcare operations. (45 CFR Parts 160, 164)
SECTION 1: INCIDENT DETAILS
Date: ________________ Time: ________Location / Unit: ________________________________
Attending Physician: ________________________________
Severity: ________________
Description:
________________________________
Immediate Actions Taken:
________________________________
SECTION 2: PATIENT CONDITION
Before Incident:________________________________
After Incident:
________________________________
SECTION 3: FAMILY / GUARDIAN NOTIFICATION
Status: ________________SECTION 4: PEOPLE INVOLVED
SECTION 5: WITNESS STATEMENTS
No witnesses reported.SECTION 6: ROOT CAUSE & CORRECTIVE ACTIONS
Contributing Factors:________________________________
Root Cause:
________________________________
Corrective Actions:
________________________________
Preventive Measures:
________________________________
Follow-Up Date: ________
Frequently Asked Questions
PATIENT INCIDENT REPORT