/Institutions/Northwestern-Health-Sciences-University/json/2019-2020/Acupuncture-and-Chinese-Medicine-Clinical-Student-Handbook-local.json

/Institutions/Northwestern-Health-Sciences-University/json/2019-2020/Acupuncture-and-Chinese-Medicine-Clinical-Student-Handbook.json

Appendix D: Incident Report

Clinic Incident Report Form

INSTRUCTIONS FOR USE OF THIS FORM: Use this form to record any incident in which:

1. A patient/client has a negative outcome/reaction or other distressing experience clinical in nature in the course of a treatment or has an accident or injury on the clinic premises.
2. A patient/client demonstrates inappropriate behavior towards a student, staff or clinical faculty member.
3. An employee of NWHSU has an accident or is injured on the clinic premises

THE REPORT IS TO BE FILLED OUT ON THE DAY OF THE INCIDENT BY THE FACULTY CLINICIAN, STUDENT SUPERVISOR OR STAFF MEMBER AND FORWARDED TO THE CLINIC ADMINISTRATOR. NOTATION OF THE INCIDENT MUST BE RECORDED IN THE PROGRESS NOTE OF THE PATIENT RECORD.

Date:	Clinic:

Incident Involved:		Needle Retention		Needle Stick		Patient Injury / Incident
		Student Injury		Other

Patient/Client Name:

Birth Date:

Home Phone:

Sex:

Male

Female

Location of incident:
Date of incident:		Date reported:
Time of incident:		Time reported:

Description of incident:

FOR NWHSU ADMINISTRATION

Date Rec’vd

Initials

Follow-up by

Date:

Witness Name: (if applicable):
Employee Completing Incident Report: