Concierge Medicine Incident Report Template

Patient Information

• Patient Name: ________________________
• Date of Birth: ________________________
• Member ID: ___________________________
• Contact Number: ______________________

Incident Details

• Date of Incident: _____________________
• Time of Incident: _____________________
• Location: ____________________________

Type of Incident (check all that apply)

□ Medical Emergency □ Medication Error □ Communication Issue □ Access/Availability Problem □ Service Quality Concern □ Privacy/HIPAA Issue □ Other: ______________________________

Incident Description

Detailed account of what occurred:

Immediate Actions Taken

1. Initial response: ___________________
2. Medical interventions (if any): _______
3. Communications made: _____________

Witnesses

• Staff present: _______________________
• Other witnesses: ____________________

Follow-up Actions

□ Patient contacted □ Documentation updated □ Care plan modified □ Quality review initiated □ Policy review needed

Resolution Plan

Report Filed By

• Name: _____________________________
• Position: __________________________
• Date: _____________________________
• Signature: _________________________

Medical Director Review

• Comments: _________________________
• Action items: _______________________
• Signature: _________________________
• Date: _____________________________