Ocean View Community Hospital

A sample hospital incident reporting form to replace a paper-based system.

	NOTE: Fields marked with "*" are required.

THIS FORM IS NOT FOR MEDICATION OCCURRENCES All major injuries or unanticipated death immediately contact administrative supervisor.
Patient Name of Visitors Identification:
OCCURRENCE REPORT Confidential data, not to be disclosed, released, or copied. Not a part of patient medical record.
Date of Occurrence (mm/dd/yyyy):
Enter Time :
Enter Age in Years:
Location of Incident:
Choose Department Where Incident Occurred:
Location of Incident:
Falls Incident Information
Was Fall Witnessed?:
Choose Most Appropriate
Fall Information:
Bed Rails:
Ambulation Privileges:
Protective Device:
Balance:
Surface Conditions:
Collision:
Medications Within Last 12 hrs:
Lighting Conditions:
Treatment & Procedures
Incident:
Difference From Order:
Counts:
Specimen:
All other incident types
Other:
Patient condition prior to occurrence
Prior Condition:
Effects
Severity of Occurrence:
Effects (select most serious):
Referred for Treatment:
Physician:
Witness:
X Ray Ordered:
Medical device failure form (safety index #808 812) completed:
Evaluation (what was the occurrence):
Conclusions (why it happened):