Dermatology Practice Incident Report Template

Patient Information

• Patient Name: ________________
• Date of Birth: ________________
• Medical Record #: ________________
• Contact Information: ________________

Incident Details

• Date of Incident: ________________
• Time of Incident: ________________
• Location: ________________
• Type of Visit: □ Regular □ Procedure □ Emergency

Nature of Incident (Check all that apply)

□ Adverse Drug Reaction □ Procedure Complication □ Equipment Malfunction □ Patient Fall/Injury □ Treatment Site Reaction □ Infection □ Other: ________________

Description of Incident

Detailed account of what occurred:

Immediate Actions Taken

1. Clinical Response: ________________
2. Patient Notification: ________________
3. Documentation in EMR: ________________

Staff Involved

• Primary Provider: ________________
• Other Staff Present: ________________
• Witnesses: ________________

Follow-up Actions

□ Patient Requires Follow-up □ Equipment Needs Inspection □ Staff Training Required □ Policy Review Needed

Risk Assessment

Severity Level: □ Minor □ Moderate □ Severe □ Critical

Reporter Information

• Name: ________________
• Role: ________________
• Date of Report: ________________
• Signature: ________________

Administrative Use Only

• Review Date: ________________
• Reviewed By: ________________
• Action Plan: ________________
• Quality Improvement Measures: ________________