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October 30, 2022

Demographic information about the patient

Procedure 42-1 Steps Start Time: End Time: Total Time: First Third Steps Possible Second Points Attempt Attempt Attempt 1 Report the incident immediately to a supervisor for 15 documentation 2. Assemble equipment 3. Fill in the demographic information about the patient 15 4. Fill in location of the event S Complete the section regarding information about the 15 patient factors prior to the event 6. Fill in the categones of event section. 15 In the space provided, give a written description of the event 8. Add any additional persons involved 15 Complete the review section 15 10 Complete the corrective action section 15 1 1 Complete the procedures followed section Complete the family patient attitude after the event 15 section Add any additional information that may be warranted and obtain signatures. titles, and dates. 14 Forward form to the rick management department following the office protocol so proper action can occur Points Awarded/Points Possible 210

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