Geriatric Care Incident Report Form

Patient Information

• Full Name: ________________
• Date of Birth: ____________
• Medical Record #: _________
• Primary Care Provider: _____

Incident Details

• Date of Incident: __________
• Time of Incident: __________
• Location: ________________

Type of Incident (check all that apply)

• Fall
• Medication Error
• Behavioral Episode
• Wandering/Elopement
• Equipment Malfunction
• Care-Related Injury
• Other: ________________

Incident Description

Detailed account of what occurred:

Contributing Factors

• Cognitive Status
• Mobility Issues
• Environmental Hazards
• Medication-Related
• Staff-Related
• Other: ________________

Immediate Actions Taken

• Time of Response: _________
• Staff Member(s) Responding: _________
• Actions: ________________

Medical Intervention

• Was medical attention required? □ Yes □ No
• Was 911 called? □ Yes □ No
• Vital Signs at Time of Incident:
  • BP: / mmHg
  • HR: ____ bpm
  • RR: ____ /min
  • O2 Sat: ____%
  • Temperature: ____°F

Notifications

• Family Notified: □ Yes □ No
  • Time: ________
  • Contact Name: ________
• Physician Notified: □ Yes □ No
  • Time: ________
  • Orders Received: ________

Follow-up Plan

Report Completed By

• Name: ________________
• Title: ________________
• Date: ________________
• Signature: ____________

Supervisor Review

• Name: ________________
• Date: ________________
• Signature: ____________