Policy Manual sample

MDT Home Health Care Agency, Inc. INCIDENT REPORT (Risk Management) Brief Incident Description: ______________________________________________ _____________________________________________________________________ 9 Negligence 9 Abandonment 9 Work Delegation Problem 9 Staffing Level 9 Staff Competency 9 Documentation Problem 9 Other ____________________ Patient Name: ________________________________ Med. Record: _____________ Agency/MD Notified: __ Yes __ No, if Yes, Date: ____________ Time: ___________ Physician Name: ______________________________ Ph: _____________________ Agency Staff notified: _____________________________ Date: ________________ Has the patient reported the problem to other parties: ___ Yes ___ No If yes, Provide the Name of the Company/Persons:__________________________ ___________________________________________________________________ ___________________________________________________________________ Phone: _______________________ Date of Report: _________________________ Problem Description: __________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Consequences of the Problem: __________________________________________ ___________________________________________________________________ ___________________________________________________________________ Action Taken: _________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Person making the Report: ______________________________________________ Signature: ____________________________ Date: ________________________ Home Health Agency Nursing Manual J-74