Incident Report THIS IS NOT A REPORT OF CLAIM NOT PART OF THE MEDICAL RECORD Name and address of per - Excel

							                                                                               Incident Report
THIS IS NOT A REPORT OF CLAIM
NOT PART OF THE MEDICAL RECORD
Name and address of person Involved                                                      Type                        Gender                                      Study
Give Medical Chart Number (if patient)                                         Patient                  Male
                                                                               Visitor                  Female
                                                                               Other
                                                                                                                        Age
                                                                                                        Years
                                                                                                        If less than one year
                                                                                                        Months
                                                                               Current Diagnosis



                Event Date                                Report Date                           Time of Event                                    Medical Device I.D.
       /            /                             /           /                          :              Am                Detail in "Describe Event" area
  Mo          Day              Year          Mo         Day             Year             :              Pm                Device Name
                                                                                                                          Device #
               Type of Event                           Location of Event                       Nature of Injury                                 Injury Severity
           Fall                                       Admin Office                           Laceration/Cut                                Emotional Only
           Medication                                 Building Exterior                      Contusion/Abrasion                            Temporary Minor
           Surgical                                   Employee Bathroom                      Fracture/Dislocation                          Temporary Major
           Test/Proc/Trmt                             Front Office                           Burn/Scald                                    Permanent Minor
           IV Related                                 Laboratory                             Sprain/Strain                                 Permanent Major
           Pers Prop Loss                             North Corridor                         Retained Foreign Body                         Death
           Equipment Related                          Nursing Area                           Allergic Reaction                             None
           Infection                                  Patient Bathroom                       Neurological Deficit                          Unknown
           Special Event, Mark Below                  Patient Waiting Room                   No Apparent Injury                         Complete Where Appropriate
           Other (Describe)                           Waiting Room Bathroom                  Other (Describe)             Orientation      Before Incident      After Incident
                                                      Procedure Room                                                      Alert
                                                      Pt Exam Room #                                                      Senile
                                                      Other (Describe)                                                    Confused
                                                                                                                          Sedated
                                                                                                                          Unconscious
                                                                                                                          Agitated/Other
                                 Description of Special Events                                                    Describe the Event: (Name, treatment, device, etc.)

           Improper result of diagnostic/therapeutic procedure
           Adverse drug reaction
           Missing gauze, needle, or instrument
           Unexpected death
           Cardiac/respiratory arrest (include newborn hypoxia)
           No written consent or improper consent for procedure
           Patient/family/staff dissatisfaction with treatment/result
           Patient refused treatment or departed AMA (against medical advise)
           Special Event-Other (Mark Below)




Patient or Witness Comments:




                                                                                             Dr/PA/NP                                       Notified at:
                                                                                             Medical/Nursing Findings:




                                                                                             Name and title of person preparing this report:




                                                                                             Supervisor's Signature



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    updated 2-27-08                                                                             ]
                                                     PURPOSE AND INSTRUCTIONS FOR INCIDENT REPORT

An incident report is to be filled out for:

1.    Patient complaint
2.    Patient or employee injury
3.    Employee needle stick
4.    Procedure that was performed improperly
5.    Loss of personal property
6.    Error in medication or vaccine administration
7.    Faulty equipment
8.    An adverse drug reaction
9.    Failure to obtain consent from patient for procedure
10.   Patient refusal of treatment or departed AMA
11.   Any other special event

Fill out all pertinent blanks as completely as possible. All information is important, including specific equipment that is faulty (i.e., table in Room 4 on south side of
building, not just exam table). Your supervisor’s signature is also very important.
This form will be returned to your supervisor within one hour of the event. The Supervisor will follow up with any pertinent information, document how issue was
resolved or addressed, and then give to their supervisor. When given to the admin team supervisor, they will forward to the Director of Clinical Services.

In case of a patient injury in the building or parking lot, Administration will be notified so that our insurance company can be notified as soon as possible.

IN CASE OF A PATIENT DISMISSAL, PLEASE GIVE A COPY OF THE DISMISSAL LETTER TO JACQUE SO THAT SHE CAN HAVE MEDICAL RECORDS
TERMINATE THE PATIENT ON THE SCHEDULED DATE (30 DAYS OUT). JACQUE WILL ALSO PROVIDER MEDICAL/DENTAL THE INFORMATION, SO
THAT PATIENT IS TERMINATED IN BOTH PLACES.
In case of an employee injury while on the job, Administration will be notified immediately so that our workman’s compensation company, Missouri Employees
Mutual (MEM), can be notified immediately. (Missouri Employee Mutual workmans compensation packets are now located in Administration area on the top shelf
above the policies and procedures.

In case of a needle stick, this form will be given to Director of Clinical Services or the assigned Safety Coordinator within 10 minutes of the incident. If the Director
of Clinical Services or the Safety Coordinator is not in the building, the Director of Clinical Services will be notified via phone immediately. The CEO will be notified
in case of no availability of the Director of Clinical Services via phone. The source patient will be kept in the building until proper needle stick protocol is followed,
including calling KTCH’s workman’s compensation company, Missouri Employees Mutual (MEM). (see instructions in OSHA Policies, pages 52 and 53. The
Director of Clinical Services will copy one incident report for QI and the original is kept in the employees medical file in Administration.




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