Free Physical Therapy Medical Incident Report Template
Physical Therapy Medical Incident Report
I. Report Information
|
Field |
Details |
|---|---|
|
Reporter's Name: |
[Your Name] |
|
Report Date: |
May 30, 2050 |
II. Incident Description
|
Field |
Details |
|---|---|
|
Incident Date: |
May 29, 2050 |
|
Incident Time: |
3:00 PM |
|
Location: |
Physical Therapy Room 2 |
III. Patient Information
|
Field |
Details |
|---|---|
|
Patient Name: |
[Patient Name] |
|
Patient Age: |
[Patient Age] |
|
Patient Contact Information: |
[Patient Contact Information] |
IV. Incident Details
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Description of Incident: The patient was undergoing a therapy session when they slipped and fell. The incident occurred as the patient was transitioning from one exercise to another and lost footing.
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Injury Sustained: The patient sustained a sprained ankle injury, which was promptly assessed by the attending therapist.
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Witnesses: [Witness Name]
V. Immediate Action Taken
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Action Taken by Staff: Immediate first aid was administered. The patient was then escorted to a more secure area, and the injury was documented. The patient was advised to seek further medical evaluation.
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Emergency Services Contacted: Yes
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Additional Notes: The attending therapist, Jane Doe, provided initial assessment and care. Emergency medical services arrived promptly and transported the patient to the hospital for further evaluation and treatment.
VI. Follow-Up
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Follow-Up Action Required: Schedule a follow-up appointment with the patient to assess recovery progress.
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Person Responsible: [Person Responsible]
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Follow-Up Date: June 5, 2050
VII. Sign-Off
Reported By: [Your Name]
Position: [Your Position]
Date: May 30, 2050
