Incident Report Sample Hospital Details

Clinical incident reports are written documents that describe an incident or event that occurred within a clinical setting. They are used to help improve patient care, and can be helpful in identifying system-wide issues. A clinical incident report sample can help you understand what information should be included in a clinical incident report. Included in this blog post is a link to a real world example of a clinical incident report, as well as an explanation of the information included in it. By understanding the purpose and content of a clinical incident report, you can ensure that your own reports are thoroughly documented and accurate.

The listing offers information about the clinical incident report sample. It is really worth making the effort to read this before starting filling in your form.

QuestionAnswer
Form NameClinical Incident Report Sample
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesclinical incident report, ocddwss pf 08 001, fillable ocddwss pf 09 002, clinical incident form

Form Preview Example

Department of Health and Hospitals

Office for Citizens with Developmental Disabilities

Home and Community Based Services (HCBS) Critical Incident Report Form

PARTICIPANT IDENTIFYING INFORMATION:

Name First:

Name Middle (if known):

 

 

 

Name Last:

 

 

 

 

 

 

 

Address:

City:

State:

Telephone #:

 

 

 

 

 

 

 

 

 

 

 

 

Region:

DOB:

 

 

SSN:

 

 

 

 

 

 

 

 

 

 

 

 

 

Parish:

Gender: Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

Name of Family/Legal Guardian:

 

 

 

Telephone of Family/Guardian:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Family/Legal Guardian Address

Service Type:

NOW

CC

SW

ROW

State

Funded

Marital Status

Single

Married

Divorced

Separated

Widowed

Race

African American

White

Hispanic

Asian/Pacific Islander

American Indian

Alaskan

Unknown/Other

Living Situation

With Relatives

With Other/Unknown

Alone

With Roommate

With Spouse

With Shared Supports

In Licensed Facility

In Unlicensed Facility

Homeless

Legal Status:

Competent Major

Interdicted

Emancipated

Minor

Continued Tutorship

Disability: Person having

Institutional Transition

Yes No

Autism

Brain/Head Injury

Cerebral Palsy

Dementia

Disease-Related

Epilepsy

Hearing Impairment

Mental Illness

MR Mild

MR Moderate

MR Profound

MR Severe

Paraplegia

Stroke

Speech Dysfunction

Quadriplegia

Substance Abuse

Visual Impairment

None Determinable

Other Physical

Other Developmental

Disability

Type:

Nursing Facility

SSC (DC)

ICF/DD (Private)

Issued 09/18/09, Effective 10/01/09; Reissued 05-12-2010

OCDDWSS-PF-09-002

Replaces July 22, 2008 OCDDWSS-PF-08-001

Page 1 of 6

Department of Health and Hospitals

Office for Citizens with Developmental Disabilities

Home and Community Based Services (HCBS) Critical Incident Report Form

Participant Name:

 

SSN:

 

 

 

 

 

 

 

 

 

INCIDENT CATEGORIES: Check only those that apply

Note: All protective services allegations must be verbally reported

Child Abuse

Primary Non Primary

Child Neglect

Primary Non Primary

Adult

Abuse

Neglect

Exploitation

Extortion

Self Neglect

Elderly

Abuse

Neglect

Exploitation

Extortion

Self Neglect

Major Injury

Fall

 

Death

 

Loss or Destruction of Home

 

 

 

 

 

Major Illness

Check if Sub Category applies:

Decubitis

Seizure

Pneumonia

Bowel

Obstruction

Major Behavioral Incident

Attempted suicide

Suicidal threats

Self Endangerment Elopement/

missing Self injury Property destruction

Offensive Sexual

Behavior

Sexual Aggression Physical

Aggression

Major Medication Incident

Pharmacy Error

Staff Error

Family Error

Participant Error

Non Adherence

Involvement with Law Enforcement

Participant arrested

Staff arrested

Staff issued a Citation for Moving Violation (while participant is in vehicle)

Participant is a victim of a crime

Restraints Use:

BEHAVIORAL

Personal

Mechanical

Chemical

MEDICAL

Personal

Mechanical

Chemical

Issued 09/18/09, Effective 10/01/09; Reissued 05-12-2010

OCDDWSS-PF-09-002

Replaces July 22, 2008 OCDDWSS-PF-08-001

Page 2 of 6

Department of Health and Hospitals

Office for Citizens with Developmental Disabilities

Home and Community Based Services (HCBS) Critical Incident Report Form

 

 

 

Participant Name:

 

SSN:

 

 

 

 

 

 

 

 

 

EVENT INFORMATION

Incident occurred Date:_______ /Time: _______

AM or

PM

Location of Incident:

 

 

Incident discovered Date:_______ /Time: _______

 

 

Home

Vehicle

AM or

PM

Community

Day Program

 

 

 

Facility

 

 

 

 

 

 

DSP notified EPS Date: ____________ /Time: ____________

AM or

DSP notified C.P. Date: ____________ /Time: ____________

AM or

DSP Notified APS Date: ____________ /Time: ____________

AM or

PM

PM

PM

DSP notified Law Enforcement Date: ____________ /Time: ____________

AM or

PM

Type of Health Care Admissions and Date of Admissions (check all that apply):

Psychiatric Hospital

Date: ____________

Rehabilitation Facility

Date: ____________

Emergency Room

Date: ____________

Nursing Home

Date: ____________

Acute Care Hospital

Date: ____________

Respite Center

Date: ____________

SS (Developmental) Center Date: ____________

Hospice

Date: ____________

Reporter Name:

Relationship:

APS

Child

Child Protection

Curator

Day Program

Direct Service Worker

DSS

EPS

Friend/Neighbor

Guardian

Home Health

Hospital

HSS

Law Enforcement

OAD

OMH

OPH

Other

Parent

Physician

Provider

Supervisor

Self

Sibling

Spouse

Support Coordinator

Under Curator

Support Coordination Agency:

 

Agency Telephone

 

#:

 

 

 

 

 

 

Support Coordinator (SC) Name:

 

SC Telephone

 

 

 

 

 

 

Direct Service Provider:

 

DSP Telephone #:

 

 

 

 

 

 

Issued 09/18/09, Effective 10/01/09; Reissued 05-12-2010

OCDDWSS-PF-09-002

Replaces July 22, 2008 OCDDWSS-PF-08-001

Page 3 of 6

Department of Health and Hospitals

Office for Citizens with Developmental Disabilities

Home and Community Based Services (HCBS) Critical Incident Report Form

HCBS Critical Incident Report Form

Participant Name:

SSN:

Critical Incident Description

Enter all information regarding the incident (i.e., Who, What, When, Where, How, et cetera). Include all specifics and details related to the incident. Include the name of individuals with the participant at the time of the incident (including relationship, address, telephone # and name of agency et cetera). Use as many pages as necessary, numbering, dating, and signing each page. (If Law Enforcement was notified, include the name of the agency, contact person, and address.)

Name of Direct Service Provider:

Date reported to SC:

Time:

Report completed by:

Telephone #:

Date:

Region:

Issued 09/18/09, Effective 10/01/09; Reissued 05-12-2010

OCDDWSS-PF-09-002

Replaces July 22, 2008 OCDDWSS-PF-08-001

Page 4 of 6

Department of Health and Hospitals

Office for Citizens with Developmental Disabilities

Home and Community Based Services (HCBS) Critical Incident Report Form

Attach Supplemental Form to continue

Critical Incident Report Description as necessary.

Each additional page must be signed and dated.

Participant Name:

SSN:

Direct Service Provider Follow-up

Enter any follow-up related to the critical incident: results of medical/dental appointments, labs, discharge instructions from hospital, change in staffing, medications, treatments, modifications to behavior support plan, team meetings, revision to ISP, etc.

Follow-up completed by:

Telephone #:

Date:

Region:

Issued 09/18/09, Effective 10/01/09; Reissued 05-12-2010

OCDDWSS-PF-09-002

Replaces July 22, 2008 OCDDWSS-PF-08-001

Page 5 of 6

the OCDD-approved data

Department of Health and Hospitals

Office for Citizens with Developmental Disabilities

Home and Community Based Services (HCBS) Critical Incident Report Form

Continue HCBS Critical Incident Report Form

Note to Support Coordinator (SC) - If the SC discovers/witnesses an Abuse, Neglect, Exploitation or Extortion incident involving a participant between the ages of 18 -59, the SC should immediately verbally report the incident to APS. The SC should complete the CIR and keep a copy for his/her record. Important: The SC shall not enter the information regarding APS Cases into

system. This only applies to APS cases, not EPS or CP.

Attach Supplemental Form Appendix C to continue Critical Incident Report Follow-up.

Each additional page must be signed and dated.

Issued 09/18/09, Effective 10/01/09; Reissued 05-12-2010

OCDDWSS-PF-09-002

Replaces July 22, 2008 OCDDWSS-PF-08-001

Page 6 of 6