Hospital And Ambulatory Surgical Center Fax Report Form Page 3
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11BODY PART AFFECTED: Use terms such as “arm”, “foot”, etc.; indicate left or right when
it applies.
PATIENT’S ACTIVITY AT TIME OF OCCURRENCE: Select the term from Table #6,
“Patient’s Activity” that best describes the patient’s activity at the time of the
occurrence. You may select “Other” and describe what happened in one or two words
if none of the examples listed are applicable to your report.
PLACE OF OCCURRENCE: Specify where the event occurred. Examples would include:
“patient’s room”, “dining room”, “shower room”, or any other short phrase that specifies
the type of setting in which the occurrence took place.
WHAT EQUIPMENT, IF ANY, WAS BEING USED AT TIME OF OCCURRENCE:
Specify if any equipment was in use, such as “Hoyer lift”, or “walker”.
ANY SAFETY PRECAUTIONS IN PLACE: Check the “yes” or “no”. If “yes”, describe
the precautions that were in place.
NARRATIVE: Describe fully what occurred. Indicate who, what, when, where, why and
how what is being reported occurred. Include information on how any person injured was
treated. If there were any unusual circumstances involved, describe these fully.
CORRECTIVE MEASURES NARRATIVE: Describe what actions have been taken in
response to the occurrence.
GENERAL INFORMATION: Please indicate your name and title, as the person preparing
this report, a phone number at which we can contact you if we need additional information,
and the date and time of the occurrence. If you are not able to determine when the event
occurred, state “unknown”.
STAFF PERSON IN CHARGE OF FACILITY AT TIME OF OCCURRENCE: Indicate
who was present and in charge at the facility (not on the unit) when the occurrence reported
happened.
NOTIFICATION: Indicate whether or not the patient’s family and physician, and police
were notified. Provide the name of the physician notified.
WITNESS INFORMATION: List the name and title for individuals who saw or heard what
occurred. Indicate if any of witnesses were directly involved in what occurred. Other
patients, visitors and volunteers should be listed as witnesses if they have direct knowledge
of what occurred.
ACCUSED INFORMATION: When reporting suspected abuse, neglect or
misappropriation, indicate the name of the accused, a phone number at which the accused
can be contacted, if the accused is a nurse, nurse aide or other licensed professional please
indicate the individual’s license or registration number. Check the appropriate block if
you are not reporting abuse, or the identity of the person(s) suspected of abuse, neglect or
misappropriation of a patient’s money or belongings is unknown. If more than one
individual is suspected, indicate on an additional sheet the other individual’s names, a
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