Neurological Incident Report Form Template

Patient Information

• Name: [First] [Middle] [Last]
• DOB: [MM/DD/YYYY]
• MRN: [Medical Record Number]
• Contact: [Phone Number]

Incident Details

• Date of Incident: [MM/DD/YYYY]
• Time of Incident: [HH:MM AM/PM]
• Location: [Specify area within practice]

Type of Incident (check all that apply)

• Fall
• Medication Error
• Adverse Reaction
• Equipment Malfunction
• Procedure Complication
• Seizure Event
• Other Neurological Event

Clinical Assessment

Patient Status at Time of Incident

• Consciousness Level: [GCS Score]
• Vital Signs: BP [ / ] | HR [ ] | RR [ ] | O2 Sat [ %]
• Neurological Symptoms: [Description]

Immediate Actions Taken

1. [Action taken]
2. [Medications administered]
3. [Consultations made]

Witness Information

• Name: [Name]
• Role: [Staff position]
• Contact: [Extension/Phone]

Follow-up Actions

• Patient admitted to hospital
• Emergency services called
• Family notified
• Primary care physician informed
• Follow-up appointment scheduled

Root Cause Analysis

Contributing Factors

1. [Factor 1]
2. [Factor 2]
3. [Factor 3]

Preventive Measures

1. [Measure 1]
2. [Measure 2]
3. [Measure 3]

Report Completion

• Completed by: [Name]
• Position: [Title]
• Date: [MM/DD/YYYY]
• Signature: _______________

Review

• Reviewed by: [Name]
• Position: [Title]
• Date: [MM/DD/YYYY]
• Signature: _______________