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