Hospital And Ambulatory Surgical Center Fax Report Form Page 5

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Table #5: Type of Harm
Bruise/Hematoma
Burn
Care Not Provided
Confinement
Death
Decline in Condition
Dislocation
Emotional Harm/Upset
Fracture
Funds
Infection
Laceration
No Harm
Other – Please Describe
Pain
Pressure Ulcer
Property
Quality of Care
Reddened Area
Rough Handling
Skin Tear
Unknown
Unwelcome Sexual Contact/Advance
Table #6: Patient’s Activity
Ambulating
Crowded Area
Getting Out of Bed
Getting Up From Chair
Other – Please Describe
Reaching
Standing/Sitting Still
Standing
Toileting
Transfer/Assist
Unknown

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