Massachusetts Board Of Registration In Medicine Professional Organization Disciplinary Action Initial Report (Page 2 of 2) in pdf

Massachusetts Board Of Registration In Medicine Professional Organization Disciplinary Action Initial Report Page 2

POD-1 (09/2011)

6. Please provide a brief narrative description of the action(s) taken. Where applicable, specify

whether the action was voluntary or involuntary.

___________________________________________________________________________

Substantiating Information

Please provide a detailed explanation of the event(s) or behavior that led to the disciplinary action(s). If

applicable, include patient information, severity and type of injury, incident date and location. If more than one

incident gave rise to the disciplinary action, or if more than one patient was involved, attach additional pages as

necessary.

Patient Name: _____________________________ Sex (M/F) ___ Date of Birth:___ __/_____/_____

Date of Incident: _____ / _____ / _____ (to _____ / _____ / _____)

Location (circle one):

01 Emergency Room

05 Outpatient

10 Clinic

14 Other: ___________

02 Labor/Delivery

06 Patient Room

11 Nursing Home

16 ICU

03 Laboratory/X-Ray/Testing

07 Hospital-Other

12 Physician's Office

04 Operating Room

09 HMO

13 Walk-In Center

--------------------------------------------------------------------------------------------------------------------------

Basis Code(s): Please refer to the attached List of Basis Codes and provide those which best

characterize the reasons for the action taken:

Basis Code: _ _ _ Basis Code:_ _ _ Basis Code:_ _ _ Basis Code:_ _ _ Basis Code:_ _ _

Brief Description of incident, or Reasons for Taking Action:

___________________________________________________________________________

Any questions concerning the completion of this form should be directed to the Data

Repository Unit at 781-876-8200. Completed forms should be mailed to the Data

Repository Counsel, Board of Registration in Medicine, 200 Harvard Mill Square, Suite

330, Wakefield, MA 01880.

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Massachusetts Board Of Registration In Medicine Professional Organization Disciplinary Action Initial Report Page 2