In the complex landscape of healthcare and patient care management, the Major Injury Determination Form serves as a critical tool for formalizing the evaluation process of injuries sustained by individuals in care facilities. This document, integral to the decision-making pathway, mandates collaboration between the facility and medical professionals to ascertain the severity of an injury and to ensure appropriate follow-up actions are taken. Essential highlights of the form include the necessity for its completion when a facility elects to rely on a physician, their designee, or an extender to determine the occurrence of a major injury rather than making an autonomous assessment. It outlines a clear timeframe within which the form must be submitted to and signed by the healthcare professional—specifically, within 24 hours for submission and 72 hours for obtaining a signed copy post-injury. The procedure for situations where a medical professional cannot or will not complete the form is also covered, emphasizing the need for prompt notification of the DIA Director (or designee) about the injury. Furthermore, the outcome of this determination—whether a major injury did occur—triggers distinct documentation and reporting requirements, each designed to protect the patient and to ensure regulatory compliance. Details required from the facility include the resident's name, injury specifics, and previous functional ability, fostering a comprehensive view of the incident. The medical professional's portion seeks a prognosis, making the distinction between major and non-major injuries, thus guiding the future care path for the resident. This form is not merely bureaucratic; it embodies a systematic approach to handle injuries in care environments diligently, ensuring the welfare of the resident is prioritized and the operational integrity of the facility is maintained.
| Question | Answer |
|---|---|
| Form Name | Major Injury Determination Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | nonmajorinjury form iowa, dia major injury determination form, iowa major injury determination form, injury determination form |
MAJOR INJURY DETERMINATION FORM
This form must be completed, IF the facility is relying on the physician, designee*, or extender to determine whether a major injury has occurred. (NOTE: The facility may independently determine that a major injury has occurred and submit a self report.)
•The facility shall submit this Form to the Physician, Designee*, or Extender within 24 hours of when the injury occurred.
•A signed copy of this Form must be obtained by the facility from the physician, designee*, or extender within 72 hours of the injury.
•If the physician, designee*, or extender refuses to complete the Form or is unavailable for completion and signature, the DIA Director (or designee) must be notified of the injury within one business day.
•If the physician, designee* or extender determines a major injury has occurred, this signed Form shall be maintained by the facility in the resident’s clinical record and the facility shall notify the department of the major injury,
•If the physician, designee*, or extender determines the injury sustained is not a major injury, this signed Form shall be maintained by the facility with the resident’s clinical record.
TO BE COMPLETED BY THE FACILITY:
Resident name: _______________________________________________
Date and time of the injury: __________________________________________
Description of injury: ____________________________________________
Circumstances of the incident causing the injury: _________________________________
Resident’s previous functional ability: ______________________________________
____________________________________________ / _______________________ Date: ____________ Time: ____________
Signature of Facility Representative Completing Form Print Name
TO BE COMPLETED BY THE PHYSICIAN, DESIGNEE*, OR EXTENDER:
Patient’s prognosis:
|
(CHECK ONE) |
____ |
After reviewing the circumstances, injury, and prognosis of the patient, I believe the injury sustained is a major injury |
pursuant to 481 Iowa Administrative Code 50.7(1)(a)(3). |
|
____ |
After reviewing the circumstances, injury and prognosis of the patient, I believe the injury sustained is NOT a major injury |
and, to the best of my knowledge, barring any complications, I believe the patient will return to his/her previous functional status.
I, ________________________________ (please print name), the attending physician, designee* of the physician, or physician
extender, of the above named patient, state that I have read the foregoing Determination Form, know the content thereof, and have made the determination of whether the patient’s injury should be designated as a major injury based on the disclosure of the above information available on this date.
_______________________________________________________ Date: _____________________ Time: _________________
Signature of Physician, Designee* of Physician, or Physician Extender
*Designee means another physician or physician extender in lieu of the attending physician.