Orthodontic Practice Incident Report Template

Comprehensive Documentation for Clinical and Administrative Incidents

Orthodontics

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Template Content

Last updated: Mar 24, 2025

Basic Information

  • Date of Incident: //___
  • Time of Incident: : AM/PM
  • Location: □ Treatment Room □ Waiting Area □ Other: _______
  • Reporter Name: _________________
  • Position: _________________

Patient Information

  • Patient Name: _________________
  • Chart Number: _________________
  • Age: ___
  • Current Treatment Phase: _________________

Incident Type

□ Clinical Incident □ Equipment Malfunction □ Patient Injury □ Staff Injury □ Property Damage □ Other: _________________

Incident Description

Detailed Account



Contributing Factors

□ Equipment Issues □ Protocol Deviation □ Communication Error □ Environmental Factors □ Other: _________________

Immediate Actions Taken




Witness Information

Name(s): _________________ Contact: _________________

Follow-up Required

□ Patient Contact □ Equipment Service □ Staff Training □ Protocol Review □ Risk Management Notification

Additional Notes



Signatures

Reporting Staff: _________________ Date: //___ Supervisor: _________________ Date: //___

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