Iowa Medicaid Critical Incident Report Page 2
ADVERTISEMENT
1
2
3
4Page 2
IOWA MEDICAID CRITICAL INCIDENT REPORT
(Please note: Complete the
section and
before completing the
section.)
Circumstances
Physical Injury Type
Injury due to:
Physical
Circumstances: (select one) Physical injury occurred
to the member
by the member to another individual.
Injury
Physical Injury Type:
Injury due to: (select all that apply)
Mechanical restraint
Physical / manual restraint
Physical injury requiring
mechanical restraint for behaviors
movement inhibited
physician’s treatment or
removal of mobility aids
take down
admission to a hospital.
impair sensory capabilities
prone restraint
(select all that apply)
other, describe __________
other, describe __________________
burn
Personal harm
Environmental condition
dislocation
aggressive behavior
fire
sprain
self-mutilation / self injurious behavior
tornado / storm
allergic reaction
suicide attempt
flooding
concussion
PICA behavior / ingestion of harmful substance
unsafe/ unhealthy physical environment
contusion / bruise
accidental fall
social environment
human/animal bite
aspiration / choking
other, describe __________________
abrasion
seizure
laceration
vehicular accident
Medication variance by member
puncture wound
assault
wrong dosage
fracture
other; describe ____________________
wrong medication
electric shock
wrong time
eye emergency
Medication variance by staff
unauthorized administration
loss/tearing of body part
wrong dosage
missed dosage
loss of consciousness
wrong medication
other, describe _______________________
poisoning/toxin ingestion
wrong time
other_______________
documentation error
unauthorized administration
missed dosage
other, describe _______________________
Apparent cause of death: (select one)
Member’s location at time of death:
Physical address where the member died:
Death
(select one)
accident
Address: _____________________________
member’s legal residence
suicide
community
City: ______________ State ____ Zip _____
homicide / violence
community job
terminal illness / natural causes
Physical illnesses/conditions were:
school
physical injury condition / situation
diagnosed prior to death
crisis stabilization
other; describe________________
discovered at time of death
unknown
day program
work activity
Complete if known:
Death of person other than member:
state facility
Was an autopsy requested?
Yes
No
Name ____________________________________
hospital / clinic
Was an autopsy performed?
Yes
No
hospice
Relationship to member: _____________________
other; describe ____________
Was there a DNR order?
Yes
No
Specifically, what were the circumstances surrounding death?
Emergency mental health treatment due to: (select all that apply)
Mental Health
condition / situation identified under physical injury
self injurious / self mutilation behavior without physical injury
condition / situation identified under law enforcement
aggressive behavior toward another without physical injury
suicidal ideation
other, describe ______________________________________
Intervention of law enforcement for: (indicate whether the member was the victim or perpetrator and select all that apply)
Law
illegal sexual behavior;
victim
perpetrator
illegal acts;
victim
perpetrator
Enforcement
possession of illegal / hazardous substances;
victim
perpetrator
property damage;
victim
perpetrator
inappropriate sexual advances;
victim
perpetrator
provoking incident;
victim
perpetrator
aggressive behavior;
victim
perpetrator
other; describe
victim
perpetrator
Please specify member’s involvement:
Report of suspected dependent adult abuse: (select all that apply)
Abuse Report
physical injury
exploitation
Member was the
victim
perpetrator
or Restriction
sexual abuse
denial of critical care
self-denial of critical care
Report of suspected child abuse: (select all that apply)
Restriction or confinement: (select all that apply)
physical injury
arrest
mental injury
as identified under physical injury
sexual abuse
PRN meds for behavior
denial of critical care
exclusionary timeout
presence of illegal drugs
seclusion / isolation
manufacture or possession of a dangerous substance
rights violation
cohabitation with a registered sex offender
cruel punishment
Location Unk
Member’s location is unknown by provider responsible for protective oversight. Please describe:
470-4698 (Rev 5/10)
(MAIL) Provider Correspondence, PO Box 36450, Des Moines, IA 50315 (FAX) 515-725-1360
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical