Incident Report Form With Instructions Page 4
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4Patient Information
If the incident involves a patient, please complete the following:
Patient’s First Name: _________________ Middle: _____________ Last: __________________
DOB: ____/____/____
Started dialysis: ____/____/____
Admitted here: ____/____/____
Diagnoses (all): _________________________________________________________________
______________________________________________________________________________
Current Condition: (check one)
Return to previous modality at this facility
In Hospital _________________________________________________ (name of hospital)
Deceased
Treatment Information
Service Type: (check one)
Access Type: (check one)
HD In-Center
Graft
Fistula
PD
Central Catheter
PD
Home HD
Current Dry Weight: _________Kg
Total Heparin Dose: _________Units Reuse #: ________
Complete the following charts for the treatment involved, the last two treatments, and
the most recent labs. Please attach copies of the last 3 treatment sheets. If the patient
is deceased, also include the mortality review of the patient.
Pulse
Blood Pressure
Weight
Hct. or Hgb.
Kt/V or URR
Potassium
Date
Pre
Post
Pre
Post
Pre
Post
Date Result Date Result Date Result
Patient Transfer
Complete this section only if the patient was transferred to another facility.
Name of Facility: _________________________________ Date of Transfer: ________________
In addition to the above information, please include the following: plan of care and reassessment of
the patient’s plan of care; evidence of interventions with the patient and/or care-giver (i.e.
progress notes); coordination with Network 14; physician’s orders; copies of letters to patient; and
copies of policies/procedures for involuntary transfer of a patient.
Signature: ______________________________________________ Date: __________________
Printed Name: ____________________________________ Title: ________________________
Forward within ten business days of incident to:
DSHS Use Only
Texas Department of State
Health Services
Reviewed by: _____ Date: ________
Facility Licensing Group
No Action required
Delivery Code 2835
Action required:
PO Box 149347
_____________________________
Austin, Texas 78714-9347
_____________________________
OR
_____________________________
FAX: 512-834-4514
Only send one way.
Form Revised 3/20/17
Do not send by both mail and fax.
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