Hospital And Ambulatory Surgical Center Fax Report Form Page 8
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4. CORRECTIVE MEASURES NARRATIVE – Please address the following:
N/A - Incident occurred with another provider _______.
Was there an internal investigation: Yes_____ No_____
If No - why? If yes - what are the investigation findings?
What action was taken with regard to: Patient?; Staff?; Facility practice? What is the patient's current status?
What corrective action taken regarding equipment involved, if applicable?
STAFF PERSON IN CHARGE OF FACILITY AT TIME OF OCCURRENCE:
N/A (Incident occurred with another provider):_______
Name:
Title:
Directly Involved:
_____________________________________________________YES_____NO_______
NOTIFICATION:
Was family notified:
Yes__________ No_____________
Was MD notified:
Yes__________ No_____________
Name of MD if notified:
_________________________________________
Were police notified:
Yes__________ No_____________
WITNESS INFORMATION:
(Check here if unwitnessed: ____________)
Name:
Title:
Directly Involved:
_____________________________________________________YES_____NO_______
_____________________________________________________YES_____NO_______
ACCUSED INFORMATION:
(Check here if unknown or not applicable: _________)
Name:
________________________________
Telephone:
(_____) _____-_______
AIDE ___; RN/LPN ____
If RN/LPN or other licensed individual, indicate license #:______________________
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