Policy Manual sample

MDT Home Health Care Agency, Inc. INCIDENT/OCCURRENCE REPORT (Use Additional Pages if Needed) ___ PATIENT OCCURRENCE ____ EMPLOYEE OCCURRENCE EMPLOYEE NAME/SOC. SEC.# _______________________________________________ PATIENT NAME/ADDRESS __________________________________________________ OTHERS ASSIGNED ________________________________________________________ DATE OF OCCURRENCE ___________________________________________________ NOTIFICATION DATE _______________________________________________________ LOCATION OF OCCURRENCE _______________________________________________ WITNESSES _______________________________________________________________ TYPE OF OCCURRENCE: Describe the occurrence and how it occurred. List all people involved or aware of the occurrence. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ INTERVENTION: Describe in detail how the Agency handled this occurrence i.e. MD referral, treatments, medications, referrals, police notification, etc. List reports which were filed. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ FOLLOW-UP: Describe in detail the follow-up, medical treatment. Agency or police action provided. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ DISPOSITION: Describe in detail how this case has been resolved. If indicated, state when/if employee can return to work. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ DATE OF RESOLUTION ___________________DATE CASE CLOSED ____________ EMPLOYEE SIGNATURE/DATE _____________________________________________ SUPERVISOR SIGNATURE/DATE ___________________________________________ ACTION TO PREVENT SIMILAR OCCURRENCE: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Home Health Agency Nursing Care & Procedures K-100