Hospital And Ambulatory Surgical Center Fax Report Form Page 10
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
115
6. RADIOLOGIC EVENTS
___ Death or serious injury of a patient or staff associated with the introduction of a metallic object into the
MRI area
7. POTENTIAL CRIMINAL EVENTS
___ Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist,
or other licensed healthcare provider
___ Abduction of a patient/resident of any age
___ Sexual abuse/assault on a patient or staff member within or on the grounds of a healthcare setting
___ Death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) that
occurs within or on the grounds of a healthcare setting
SRE ATTESTATION: (please check boxes to confirm the statements):
□
This report is being made within 7 calendar days of the discovery of the event.
□
The patient or patient’s representative has been notified verbally and in writing about:
•
the occurrence of the SRE including unanticipated outcomes of care, treatment and services provided as
the result of an SRE
•
the facility’s policies and procedures and documented review process for making a preventability
determination
•
the option to receive a copy of the report filed with the Department
□
A copy of this report is being provided to any responsible third-party payer.
PATIENT INSURER:
_____________
INSURANCE IDENTIFICATION NUMBER:
_____________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Cms-2802d - Request For Validation Of Accreditation Survey For Ambulatory Surgical Center
Medical
Form Cms-377 - Ambulatory Surgical Center Request For Initial Certification Or Update Of Certification Information In The Medicare Program
Medical
Form Car - Cemetery Permanent Maintenance And Merchandise Trust Funds Annual Report Form - Secretary Of State
Legal
Related Categories
Parent category: Business