Endodontic Incident Report Form Template

Patient Information

• Patient Name: ________________
• Date of Birth: ________________
• Chart Number: ________________
• Date of Incident: ________________
• Time of Incident: ________________

Incident Details

Type of Incident (check all that apply)

• Instrument Separation
• Perforation
• Sodium Hypochlorite Accident
• Wrong Tooth Treatment
• Adverse Drug Reaction
• Other (specify): ________________

Location of Incident

• Tooth Number: ________________
• Specific Area: ________________

Description of Incident

Detailed account of what occurred: ________________

Immediate Actions Taken

1. Clinical interventions: ________________
2. Patient notification: ________________
3. Emergency measures: ________________

Assessment

Contributing Factors

• Equipment Failure
• Procedural Complexity
• Patient Factors
• Communication Issues
• Other: ________________

Severity Assessment

• Minor - No harm caused
• Moderate - Temporary harm
• Major - Permanent harm
• Critical - Life-threatening

Follow-up Actions

Patient Care Plan

• Immediate treatment modifications: ________________
• Follow-up appointment scheduled: ________________
• Referral required: Yes [ ] No [ ]

Documentation

• Patient record updated
• Clinical photographs taken
• Radiographs obtained
• Patient informed consent documented

Reporting

Completed by: ________________ Position: ________________ Date: ________________

Reviewed by: ________________ Position: ________________ Date: ________________