Report Of Nursing Practice Incident Confidential printable pdf download

OKLAHOMA BOARD OF NURSING

elephone: 405/962-1800

Fax:

405/962-1819

2915 N. Classen Blvd., Suite 524

Oklahoma City, OK 73106

Website:

REPORT OF NURSING PRACTICE INCIDENT

CONFIDENTIAL

Date of Report:

Date of Occurrence(s): _______________________

1. Name of Nurse you are reporting:______________________________________________

Oklahoma Certificate No.: ______________________ SSN: _________________________

Address: ___________________________________________________________________

(Street)

(City)

(State)

(Zip)

Phone #: (W) ___________________ (H) _____________________ (C) ________________

2. Narrative Report of What Occurred: ___________________________________________

______________________________________________________________________________

Narrative Report of Investigation of Incident and Action Taken by Agency: _____________

______________________________________________________________________________

Attach Copies of Documents to Support Allegations, including but not limited to Narcotic

records, MAR, nursing notes, physician orders, treatment sheets, incident reports, drug screens

and signed and dated statements from witnesses. (If necessary, attach additional pages).

The Oklahoma Board of Nursing is a health oversight agency as defined in the Health Insurance

Portability & Accountability Act of 1996 (HIPAA), Public Law 104-191, [the (“Privacy Rule”)],

and as such covered entities may disclose protected health information to health oversight

agencies for the purposes of legally authorized health oversight activities, such as audits and

investigations necessary for oversight of the health care system and government benefit

programs, without an individual’s authorization for permission. (See the Privacy Rule [45

CFR §164.512(d)].

3. Name of Individual Making Report: _______________________ Title: _______________

Agency/Hospital: __________________________ Agency Phone #: (___)______________

Address: __________________________________________________________________

(Street)

(City)

(State)

(Zip)

4. Witnesses: on a separate sheet of paper please provide the name, home phone number and

home address of all witnesses. [Please provide this essential information].

The information included herein is true and correct to the best of my knowledge and belief.

________________________________

Signature

Revised 02/1989; 09/25/2000; 02/07/2001; 03/30/2001; 02/12/2004; 01/11/2007; 04/16/07; 06/18/07: 07/05/07

Report Of Nursing Practice Incident Confidential

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