Hospital And Ambulatory Surgical Center Fax Report Form Page 4

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phone number at which they may be contacted, and if any person was acting as a nurse
aide, home health aide or homemaker.
REPORTING TABLES:
Table #4: Incident/Allegation Type (cont.)
Closure
Table #1: Ambulatory Status
Criminal Act
Independent
Death
Supervised
Dental Services
Ambulates with Assistance
Dietary Services
Dependent/Assist
Elopement/Missing Person
Walks with Cane/Walker
Emergency Care
Wheels Self
Epidemic/Disease
Wheelchair
Equipment Malfunction
Bedfast
Fall – Fracture
Other
Fall – Laceration
Unknown
Fall – Other
Fire
Fraud/False Billing
Table #2: Patient’s ADL Status
HCFRS Enrollment
Independent
Infection Control
Supervised
Injury – Burn
Dependent
Injury – Fracture
Requires verbal cues
Injury – Laceration
Requires physical assist
Injury – Other
Other
Laboratory Services
Unknown
Local Laws Violation (permits, etc.)
Maternal Death
Medical Records
Table #3: Patient’s Cognitive Status
Medication Incident
Misappropriation
Alert/Oriented
Confused
Missing Personal Property
Alzheimer’s
Neglect
Developmentally Delayed
Notification of Records Destruction
Dementia
Nursing Services
Comatose
Pharmacy Services
Mental Illness/Psych History
Physical Environment
Unknown
Physician Services
Other
Pressure Ulcer
Quality of Care/Treatment
Quality of Life
Table #4: Incident/Allegation Type
Rehabilitation Services
Abuse by Staff – Physical
Resident/Patient Rights
Abuse by Staff – Sexual
Resident/Patient to Resident/Patient Incident
Abuse by Staff – Verbal
Restraint
Abuse by Visitor/Resident/Other
Staff Credentialing
Abuse – Policies and Procedures
Strike/Pending Strike
Administration
Suicide/Suicide Attempt
Advocacy Office Violation
Surgical Services
Beds Out of Service
Transfer/Discharge
Blood and Transfusion Services
Unknown/Other
Change in Beds/Services
Change of Location
Change of Ownership
Choking/Aspiration Incident

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