Critical Incident Report
Incident Date & Time:
*
Total Persons Involved:
*
1
2
3
4
5
6
7
8
9
10
Type of incident:
*
Select incident
Accidental Death
Adverse Medication Reaction
Alleged Consumer Abuse
Alleged Criminal Activity
Alleged Neglect
Alleged Sexual Abuse
Alleged Sexual Activity
Aggression or violence
AWOL
AWOL Returned
Consumer Fall
Consumer Injury
Consumer Self Abuse
Weapon Possession/Use
Death
Death of Consumer
Death of Staff
Exploitation
Falsification of Urine Specimen
Fire
Fire Alarm
Communicable disease
Loitering
Medical Emergency
Medication Error
Medication Incident
Missing Person
Natural Death
Other
Physician's Order Errors
Property Damage
Psychiatric Emergency
Restraint
Selling Drugs
Sexual Assault
Staff Fall
Staff Injury
Suicidal Threat
Suicide
Suicide Attempt
Suspicion of Selling Drugs
Unexplained Death
Vehicular accidents
Visitor Fall
Visitor Injury
Witness
Seclusion
Infection Control Incident
Wandering
Biohazardous Accident
Unauthorized Substance Use/Possession
Overdose
Type
*
Client
Staff
Visitor
Client Name:
*
Chart/Client No:
Position:
Did injury require:
*
Off-site
medical care
Physician or Nurse
on-site attention
First
aid-care
No care
Were standard precautions used:
*
Yes
No
N/A
If staff injury, was HR notified:
*
Yes
N0
N/A
Indicate attached documents:(check all that apply)
Refusal of
Medical Care
Progress
Notes
Medication Error
Report
Other
Attach Documents:
Attach Documents
Click here to choose file
Incident Description: (Facts only: what, when, who, how)
*
Immediate Action Taken:
*
Pertinent consumer and/or other information: (Diagnosis, Medications)
*
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