Occupational Therapy Incident Report Form Template

Basic Information

• Date and Time of Incident: //___ at : AM/PM
• Location: _________________
• Patient Name: _________________
• MRN: _________________
• Therapist Name: _________________

Incident Details

Type of Incident (check all that apply)

□ Fall □ Equipment-related □ Treatment-related injury □ Patient complaint □ Security incident □ Other: _________________

Description

Detailed Account of Incident:

Contributing Factors:

Immediate Actions Taken:

Assessment

Patient Status

□ No apparent injury □ Minor injury - describe: _________________ □ Serious injury - describe: _________________ □ Required emergency services

Notifications Made

□ Supervising therapist □ Physician □ Family/caregiver □ Emergency services □ Practice manager

Follow-up Actions

Medical Intervention Required

□ None □ First aid □ Emergency room □ Other: _________________

Prevention Plan

Recommended Actions:

Equipment/Environmental Modifications:

Signatures

• Reporting Therapist: _________________ Date: //___
• Supervisor Review: _________________ Date: //___

Additional Notes