Incident Report Templates - Download as Excel

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Incident Report Templates - Download as Excel Powered By Docstoc
					                             Plan Name:
              Plan 7-Digit Medicaid ID#:
               As of Date (Month/Year):
                            AHCA Area: 01 Non-Reform


                         CRITICAL INCIDENTS SUMMARY

                             Incident Type                                      # of Events:
Enrollee Death - Suicide
Enrollee Death - Homicide
Enrollee Death - Abuse/Neglect
Enrollee Death - Other
Enrollee Injury or Illness
Sexual Battery
Medication Errors - Acute Care
Medication Errors - Children
Enrollee Suicide Attempt
Altercations Requiring Medical Interventions
Enrollee Escape
Enrollee Elopement
Other Reportable Incidents
                                                                   Total                  0


Monthly - Due on the 15th of the month and contains the previous calendar month's data.
                             Plan Name:
              Plan 7-Digit Medicaid ID#:
               As of Date (Month/Year):
                            AHCA Area: 02 Non-Reform


                         CRITICAL INCIDENTS SUMMARY

                             Incident Type                                      # of Events:
Enrollee Death - Suicide
Enrollee Death - Homicide
Enrollee Death - Abuse/Neglect
Enrollee Death - Other
Enrollee Injury or Illness
Sexual Battery
Medication Errors - Acute Care
Medication Errors - Children
Enrollee Suicide Attempt
Altercations Requiring Medical Interventions
Enrollee Escape
Enrollee Elopement
Other Reportable Incidents
                                                                   Total                  0


Monthly - Due on the 15th of the month and contains the previous calendar month's data.
                             Plan Name:
              Plan 7-Digit Medicaid ID#:
               As of Date (Month/Year):
                            AHCA Area: 03 Non-Reform


                         CRITICAL INCIDENTS SUMMARY

                             Incident Type                                      # of Events:
Enrollee Death - Suicide
Enrollee Death - Homicide
Enrollee Death - Abuse/Neglect
Enrollee Death - Other
Enrollee Injury or Illness
Sexual Battery
Medication Errors - Acute Care
Medication Errors - Children
Enrollee Suicide Attempt
Altercations Requiring Medical Interventions
Enrollee Escape
Enrollee Elopement
Other Reportable Incidents
                                                                   Total                  0


Monthly - Due on the 15th of the month and contains the previous calendar month's data.
                             Plan Name:
              Plan 7-Digit Medicaid ID#:
               As of Date (Month/Year):
                            AHCA Area: 04 Non-Reform


                         CRITICAL INCIDENTS SUMMARY

                             Incident Type                                      # of Events:
Enrollee Death - Suicide
Enrollee Death - Homicide
Enrollee Death - Abuse/Neglect
Enrollee Death - Other
Enrollee Injury or Illness
Sexual Battery
Medication Errors - Acute Care
Medication Errors - Children
Enrollee Suicide Attempt
Altercations Requiring Medical Interventions
Enrollee Escape
Enrollee Elopement
Other Reportable Incidents
                                                                   Total                  0


Monthly - Due on the 15th of the month and contains the previous calendar month's data.
                             Plan Name:
              Plan 7-Digit Medicaid ID#:
               As of Date (Month/Year):
                            AHCA Area: 05 Non-Reform


                         CRITICAL INCIDENTS SUMMARY

                             Incident Type                                      # of Events:
Enrollee Death - Suicide
Enrollee Death - Homicide
Enrollee Death - Abuse/Neglect
Enrollee Death - Other
Enrollee Injury or Illness
Sexual Battery
Medication Errors - Acute Care
Medication Errors - Children
Enrollee Suicide Attempt
Altercations Requiring Medical Interventions
Enrollee Escape
Enrollee Elopement
Other Reportable Incidents
                                                                   Total                  0


Monthly - Due on the 15th of the month and contains the previous calendar month's data.
                             Plan Name:
              Plan 7-Digit Medicaid ID#:
               As of Date (Month/Year):
                            AHCA Area: 06 Non-Reform


                         CRITICAL INCIDENTS SUMMARY

                             Incident Type                                      # of Events:
Enrollee Death - Suicide
Enrollee Death - Homicide
Enrollee Death - Abuse/Neglect
Enrollee Death - Other
Enrollee Injury or Illness
Sexual Battery
Medication Errors - Acute Care
Medication Errors - Children
Enrollee Suicide Attempt
Altercations Requiring Medical Interventions
Enrollee Escape
Enrollee Elopement
Other Reportable Incidents
                                                                   Total                  0


Monthly - Due on the 15th of the month and contains the previous calendar month's data.
                             Plan Name:
              Plan 7-Digit Medicaid ID#:
               As of Date (Month/Year):
                            AHCA Area: 07 Non-Reform


                         CRITICAL INCIDENTS SUMMARY

                             Incident Type                                      # of Events:
Enrollee Death - Suicide
Enrollee Death - Homicide
Enrollee Death - Abuse/Neglect
Enrollee Death - Other
Enrollee Injury or Illness
Sexual Battery
Medication Errors - Acute Care
Medication Errors - Children
Enrollee Suicide Attempt
Altercations Requiring Medical Interventions
Enrollee Escape
Enrollee Elopement
Other Reportable Incidents
                                                                   Total                  0


Monthly - Due on the 15th of the month and contains the previous calendar month's data.
                             Plan Name:
              Plan 7-Digit Medicaid ID#:
               As of Date (Month/Year):
                            AHCA Area: 08 Non-Reform


                         CRITICAL INCIDENTS SUMMARY

                             Incident Type                                      # of Events:
Enrollee Death - Suicide
Enrollee Death - Homicide
Enrollee Death - Abuse/Neglect
Enrollee Death - Other
Enrollee Injury or Illness
Sexual Battery
Medication Errors - Acute Care
Medication Errors - Children
Enrollee Suicide Attempt
Altercations Requiring Medical Interventions
Enrollee Escape
Enrollee Elopement
Other Reportable Incidents
                                                                   Total                  0


Monthly - Due on the 15th of the month and contains the previous calendar month's data.
                             Plan Name:
              Plan 7-Digit Medicaid ID#:
               As of Date (Month/Year):
                            AHCA Area: 09 Non-Reform


                         CRITICAL INCIDENTS SUMMARY

                             Incident Type                                      # of Events:
Enrollee Death - Suicide
Enrollee Death - Homicide
Enrollee Death - Abuse/Neglect
Enrollee Death - Other
Enrollee Injury or Illness
Sexual Battery
Medication Errors - Acute Care
Medication Errors - Children
Enrollee Suicide Attempt
Altercations Requiring Medical Interventions
Enrollee Escape
Enrollee Elopement
Other Reportable Incidents
                                                                   Total                  0


Monthly - Due on the 15th of the month and contains the previous calendar month's data.
                             Plan Name:
              Plan 7-Digit Medicaid ID#:
               As of Date (Month/Year):
                            AHCA Area: 10 Non-Reform


                         CRITICAL INCIDENTS SUMMARY

                             Incident Type                                      # of Events:
Enrollee Death - Suicide
Enrollee Death - Homicide
Enrollee Death - Abuse/Neglect
Enrollee Death - Other
Enrollee Injury or Illness
Sexual Battery
Medication Errors - Acute Care
Medication Errors - Children
Enrollee Suicide Attempt
Altercations Requiring Medical Interventions
Enrollee Escape
Enrollee Elopement
Other Reportable Incidents
                                                                   Total                  0


Monthly - Due on the 15th of the month and contains the previous calendar month's data.
                             Plan Name:
              Plan 7-Digit Medicaid ID#:
               As of Date (Month/Year):
                            AHCA Area: 11 Non-Reform


                         CRITICAL INCIDENTS SUMMARY

                             Incident Type                                      # of Events:
Enrollee Death - Suicide
Enrollee Death - Homicide
Enrollee Death - Abuse/Neglect
Enrollee Death - Other
Enrollee Injury or Illness
Sexual Battery
Medication Errors - Acute Care
Medication Errors - Children
Enrollee Suicide Attempt
Altercations Requiring Medical Interventions
Enrollee Escape
Enrollee Elopement
Other Reportable Incidents
                                                                   Total                  0


Monthly - Due on the 15th of the month and contains the previous calendar month's data.
                             Plan Name:
              Plan 7-Digit Medicaid ID#:
               As of Date (Month/Year):
                            AHCA Area: 04 Reform


                         CRITICAL INCIDENTS SUMMARY

                             Incident Type                                      # of Events:
Enrollee Death - Suicide
Enrollee Death - Homicide
Enrollee Death - Abuse/Neglect
Enrollee Death - Other
Enrollee Injury or Illness
Sexual Battery
Medication Errors - Acute Care
Medication Errors - Children
Enrollee Suicide Attempt
Altercations Requiring Medical Interventions
Enrollee Escape
Enrollee Elopement
Other Reportable Incidents
                                                                   Total                  0


Monthly - Due on the 15th of the month and contains the previous calendar month's data.
                             Plan Name:
              Plan 7-Digit Medicaid ID#:
               As of Date (Month/Year):
                            AHCA Area: 10 Reform


                         CRITICAL INCIDENTS SUMMARY

                             Incident Type                                      # of Events:
Enrollee Death - Suicide
Enrollee Death - Homicide
Enrollee Death - Abuse/Neglect
Enrollee Death - Other
Enrollee Injury or Illness
Sexual Battery
Medication Errors - Acute Care
Medication Errors - Children
Enrollee Suicide Attempt
Altercations Requiring Medical Interventions
Enrollee Escape
Enrollee Elopement
Other Reportable Incidents
                                                                   Total                  0


Monthly - Due on the 15th of the month and contains the previous calendar month's data.

				
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Description: Incident Report Templates document sample