Urgent Care Incident Report Template

Basic Information

• Date and Time of Incident: //___ Time: : AM/PM
• Location Within Facility: _________________________
• Staff Member Completing Report: ___________________

Patient Information

• Patient Name: _________________________________
• DOB: //___
• Medical Record Number: _________________________
• Chief Complaint: _______________________________

Incident Details

Type of Incident (check all that apply)

• Patient Fall
• Medication Error
• Equipment Malfunction
• Security Incident
• Treatment Complication
• Diagnostic Error
• Other: ____________________________________

Incident Description

Detailed account of what occurred:

Immediate Actions Taken

Witness Information

• Names of Staff Present: ________________________
• Names of Other Witnesses: ______________________

Patient Outcome

• No Apparent Injury
• Minor Injury - First Aid Only
• Required Additional Treatment
• Transfer to Emergency Department
• Other: ____________________________________

Follow-up Actions

Required Notifications

• Medical Director
• Risk Management
• Patient's Primary Care Provider
• Other: ____________________________________

Prevention Plan

Steps to prevent future occurrences:

Signatures

Completed by: _________________ Date: //___ Reviewed by: __________________ Date: //___

Submit completed form to Practice Manager within 24 hours of incident