Comprehensive Documentation for Clinical and Administrative Incidents
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□ Clinical Incident □ Equipment Malfunction □ Patient Injury □ Staff Injury □ Property Damage □ Other: _________________
□ Equipment Issues □ Protocol Deviation □ Communication Error □ Environmental Factors □ Other: _________________
Name(s): _________________ Contact: _________________
□ Patient Contact □ Equipment Service □ Staff Training □ Protocol Review □ Risk Management Notification
Reporting Staff: _________________ Date: //___ Supervisor: _________________ Date: //___
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