Incident Report Form
DAVENPORT GALESBURG (IA) ILLINOIS (GB) BULLHEAD LAUGHLIN
HAVASU HENDERSON OAK GROVE OTHER:
EVENT INVOLVED: PATIENT EMPLOYEE FACILITY PHYSICIAN PHARMACY
INCIDENT LOCATION: HOME FACILITY HOSPITAL OTHER:
PATIENT/EMPLOYEE INFORMATION:
Complaint/Incident Concerning Employee: YES NO Name of Employee:
Pt/PCG Name:
Medical Record # PRIMARY DIAGNOSIS:
Address: County/State: Zip-code
Telephone: ( )
REPORTING PERSON INFORMATION:
NAME: Title:
Date Reported to Supervisor: Patient’s Case Manager Name:
Date of Incident TYPE OF INCIDENT: REVOCATION TRANSFER NO LONGER MEDICALLY ELIGIBLE
DISCHARGE OUT OF SERVICE AREA DISCHARGE FOR CAUSE COMPLAINT DME/Medication ISSUES
OTHER - SPECIFY:
Patient/PCG seeking aggressive treatment: YES NO Related to hospice diagnosis: YES NO
Patient went to emergency room: YES NO Was patient admitted to hospital: YES NO
What aggressive treatment was being sought and how was it related and/or non-related to hospice diagnosis:
Medical Director involved in related/non-related determination? YES NO
SUMMARY OF INCIDENT:
FOLLOW-UP/OUTCOME
EDUCATION PROVIDED: YES NO WRITTEN VERBAL
Description of education given:
INCIDENT RESOLVED? YES NO
Explain:
PCM/Administrator notified prior to discharge: YES NO
Date Notified:
Submitted to Clinical Panel prior to discharge: YES NO
Date Submitted to Clinical Panel:
Physician notified: YES NO Date: Time: Orders: YES NO
What orders were given:
Incident Report Completed By: DATE:
Incident Report must be filled out completely. All Incident Reports are to be submitted to the Incident Report Email within 24 hours of incident. If there is investigation and follow-up pending, place a note in the body of the email, stating this. Incident Report follow-up will be expected in 72 hours after the initial Incident Report is submitted
too the Incident Report Email.
In the subject line of the email you will need the following information: Patient last name, First Initial, Medical Record Number and the reason for Incident report.
EFFECTIVE IMMEDIATELY: THE COMPLIANCE DEPARTMENT WILL RETURN ALL INCIDENT REPORTS THAT DO NOT FOLLOW THIS PROCESS.
NHM-504-O