Nurse Incident Report
I. Reporter Information
Section | Information |
|---|
Reporter Name | [Your Name] |
Reporter Email | [Your Email] |
Reporter Phone Number | [Your Company Number] |
Position/Title | Registered Nurse |
II. Organization Details
Section | Information |
|---|
Organization Name | [Your Company Name] |
Organization Address | [Your Company Address] |
Organization Phone | [Your Company Number] |
Organization Website | [Your Company Website] |
Organization Social | [Your Company Social Media] |
III. Incident Details
Section | Information |
|---|
Incident Location | Patient Room 305 |
Incident Date | May 15, 2050 |
Incident Time | 10:30 AM |
Patient Name | [Patient's Name] |
Patient ID | 123456 |
IV. Incident Description
On May 15, 2050 at approximately 10:30 AM, the patient, [Patient's Name], experienced a fall incident in Patient Room 305. The patient was attempting to get out of bed without assistance and tripped over the IV pole. The fall resulted in the patient landing on their right side.
Immediately following the fall, the patient was assessed for injuries by myself, [Your Name], and was found to have a minor laceration on the right forearm and bruising on the right hip.
The attending physician, Dr. [Doctor's Name], was notified and conducted a further examination. An X-ray was performed, indicating no fractures.
V. Witness Information
Here's the information structured as a table:
Section | Information |
|---|
Witness Name | [Witness Name] |
Witness Position | Certified Nursing Assistant |
Witness Statement | "I heard a noise and immediately rushed to the patient's room where I found John Doe on the floor. I then called for the nurse on duty." |
VI. Immediate Actions Taken
Patient was assessed for injuries.
Attending physician notified and examination conducted.
X-ray performed showing no fractures.
Wound on forearm cleaned and dressed.
Patient monitored for any signs of complications.
VII. Follow-Up Actions
Implement non-skid footwear for the patient.
Reassessment of fall risk and adjustment of fall prevention protocols for the patient.
In-service training conducted for staff on assisting patients with mobility.
VIII. Reporting Nurse Statement
I affirm that the information provided in this incident report is accurate and complete to the best of my knowledge.
Reporting Nurse Name: [Your Name]
Date: May 15, 2050
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