Physical Therapy Incident Report Template and Guidelines

Basic Information

• Date and Time of Incident: [MM/DD/YYYY] [HH:MM]
• Location: [Specify treatment room/area]
• Patient Name: [Last, First, MI]
• Medical Record Number: [MRN]
• Treating Physical Therapist: [Name, Credentials]

Incident Details

Type of Incident (check all that apply)

• Patient Fall
• Equipment Malfunction
• Treatment-Related Injury
• Adverse Response to Treatment
• Security Incident
• Other [Specify]

Description of Incident

[Provide detailed, objective account of what occurred]

Contributing Factors

• Environmental Conditions: [Describe]
• Equipment Involved: [List/Describe]
• Patient Condition/Status: [Describe]

Immediate Actions Taken

1. Initial Response: [Detail immediate steps taken]
2. Medical Intervention Required: Yes/No
3. Emergency Services Called: Yes/No

Witness Information

• Name(s): [List all witnesses]
• Role(s): [Staff/Patient/Visitor]
• Contact Information: [Phone/Email]

Follow-up Actions

• Patient's Physician Notified
• Family/Emergency Contact Notified
• Risk Management Notified
• Equipment Removed from Service
• Incident Documented in EMR

Prevention Plan

1. Root Cause Analysis: [Document findings]
2. Corrective Actions: [List specific steps]
3. Staff Education Needed: [Specify requirements]

Signatures

• Reporting Staff Member: _________________ Date: _______
• Supervisor Review: _____________________ Date: _______
• Risk Management Review: ________________ Date: _______

Submit completed form within 24 hours of incident