Psychiatric Practice Incident Report Form

Basic Information

• Date of Incident: ________________
• Time of Incident: ________________
• Location: ________________
• Report Completed By: ________________

Patient Information

• Patient Name: ________________
• DOB: ________________
• Medical Record #: ________________

Incident Details

Type of Incident (check all that apply)

• Aggressive/Violent Behavior
• Self-Harm Attempt
• Medication Error
• Fall
• Security Breach
• HIPAA Violation
• Equipment Malfunction
• Other: ________________

Severity Level

• Level 1 - Near Miss
• Level 2 - Minor Incident
• Level 3 - Moderate Incident
• Level 4 - Serious Incident
• Level 5 - Critical Incident

Description of Incident

Provide detailed account of what occurred:

Immediate Actions Taken

• First Aid Administered
• Emergency Services Called
• De-escalation Procedures Implemented
• Security Notified
• Family/Guardian Contacted
• Other: ________________

Witnesses

Name: ________________ Role: ________________ Name: ________________ Role: ________________

Follow-up Actions

Required Notifications

• Attending Psychiatrist
• Practice Administrator
• Risk Management
• Legal Department
• State Authorities
• Insurance Provider

Prevention Plan

Detail measures to prevent future occurrences:

Signatures

Reporting Staff: ________________ Date: ________________ Supervisor Review: ________________ Date: ________________

Form ID: PSY-IR-[DATE]-[Sequential Number]