Cardiology Incident Report Form Template

Patient Information

• Full Name: ________________
• Date of Birth: ____________
• Medical Record #: _________
• Date of Incident: _________
• Time of Incident: _________
• Location: ________________

Type of Incident (Check all that apply)

□ Medication Error □ Procedure Complication □ Equipment Malfunction □ Patient Fall □ Cardiac Emergency □ Delayed Treatment □ Other: __________________

Clinical Details

Vital Signs at Time of Incident

• BP: / mmHg
• HR: ____ bpm
• RR: ____ /min
• O2 Sat: ____% on ____
• Temperature: ____°F/°C

Cardiac-Specific Information

• Current Cardiac Rhythm: _________
• Most Recent EKG Findings: _______
• Active Cardiac Medications: ______

Incident Description

Provide detailed account of the event:

Immediate Actions Taken

Notifications Made

□ Attending Physician □ Charge Nurse □ Department Head □ Risk Management □ Family/Next of Kin

Follow-up Actions Required

Report Completed By

Name: _____________________ Title: _____________________ Signature: _________________ Date/Time: ________________

Supervisor Review

Name: _____________________ Signature: _________________ Date/Time: ________________