Demographics Date of report: Medical record No: Admit Date: Nature of event: Date: Time: Patient Name: Age: Gender: Diagnosis: Level of Activation: Other Pertinent Information: Report completed by: Source of information (√) Trauma nurse coordinators PIPS coordinator Conference Physician Rounds Registry Impact (√) Physical: Psychological: Legal: No harm No harm Risk management contacted No detectable harm No detectable harm Complaint registered Mild temporary harm Mild temporary harm Suit filed Mild permanent harm Mild permanent harm Case dropped Moderate temporary harm Moderate temporary harm Case dismissed Moderate permanent harm Moderate permanent harm Settled Severe temporary harm Severe temporary harm Defense Verdict Severe permanent harm Severe permanent harm Plaintiff Verdict Death Profound mental harm Patient/family satisfaction: Social: Employment: Extremely satisfied Unable to socialize Employed Satisfied Homebound, able to socialize Seeking employment Neutral No social impediments, not socially active Part-time employment Dissatisfied Socially active Unemployed Extremely dissatisfied Not employable Type (√) Communication: Patient Management: Inaccurate or incomplete information Airway Nutritional Consultation or referral Questionable advice & Breathing Urologic Resource utilization Interpretation Circulation Orthopedic Resuscitation Questionable consent process Neurologic Delegation of care or tasks Intensive care Questionable disclosure process Gastrointestinal Patient care flow/tracking Wound care Questionable documentation Patient follow-up Clinical Performance Interventional: Post-Interventional: Pre-Interventional: Correct procedure with complications Correct prognosis Correct diagnosis questionable intervention Correct procedure, incorrectly performed Inaccurate prognosis Inaccurate diagnosis Correct procedure but untimely Incomplete prognosis Incomplete diagnosis Omission of essential procedure Questionable prognosis Questionable diagnosis Procedure contraindicated Procedure not indicated Questionable procedure Wrong patient Domain (√) Setting: Hospital Psychiatric Unit Ambulatory care Rehabilitation Phase: Target: Catheterization laboratory Other Evaluation Cosmetic Clinical ward Non-Hospital Resuscitation Diagnostic Diagnostic procedures EMS Transport vehicle Operative Other Emergency room Home Critical Care Palliative Hospice Hospice Recovery Preventative Inpatient Mental Health Long-Term Care facility Rehabilitation Reconstructive Inpatient Rehabilitation Mental Health Facility Rehabilitative Intensive Care Unit Nursing home Research Interventional Radiology Practitioner’s office Therapeutic Operating Room Psychiatric Hospital Outpatient Behavioral Health Rehabilitation facility Pharmacy facility Physical Therapy Scene Domain (√) - continued
Demographics Date of report: Medical record No: Admit Date: Nature of event: Date: Time: Patient Name: Age: Gender: Diagnosis: Level of Activation: Other Pertinent Information: Report completed by: Source of information (√) Trauma nurse coordinators PIPS coordinator Conference Physician Rounds Registry Impact (√) Physical: No harm No detectable harm Mild temporary harm Mild permanent harm Moderate temporary harm Moderate permanent harm Severe temporary harm Severe permanent harm Death Psychological: No harm No detectable harm Mild temporary harm Mild permanent harm Moderate temporary harm Moderate permanent harm Severe temporary harm Severe permanent harm Profound mental harm Legal: Risk management contacted Complaint registered Suit filed Case dropped Case dismissed Settled Defense Verdict Plaintiff Verdict Patient/family satisfaction: Extremely satisfied Satisfied Neutral Dissatisfied Extremely dissatisfied Social: Unable to socialize Homebound, able to socialize No social impediments, not socially active Socially active Employment: Employed Seeking employment Part-time employment Unemployed Not employable Type (√) Communication: Inaccurate or incomplete information Questionable advice & Interpretation Questionable consent process Questionable disclosure process Questionable documentation Patient Management: Airway Breathing Circulation Neurologic Gastrointestinal Nutritional Urologic Orthopedic Delegation of care or tasks Patient care flow/tracking Patient follow-up Consultation or referral Resource utilization Resuscitation Intensive care Wound care Clinical Performance Pre-Interventional: Correct diagnosis questionable intervention Inaccurate diagnosis Incomplete diagnosis Questionable diagnosis Interventional: Correct procedure with complications Correct procedure, incorrectly performed Correct procedure but untimely Omission of essential procedure Procedure contraindicated Procedure not indicated Questionable procedure Wrong patient Post-Interventional: Correct prognosis Inaccurate prognosis Incomplete prognosis Questionable prognosis Domain (√) Setting: Hospital Psychiatric Unit Ambulatory care Rehabilitation Catheterization laboratory Other Clinical ward Non-Hospital Diagnostic procedures EMS Transport vehicle Emergency room Home Hospice Hospice Inpatient Mental Health Long-Term Care facility Inpatient Rehabilitation Mental Health Facility Intensive Care Unit Nursing home Interventional Radiology Practitioner’s office Operating Room Psychiatric Hospital Outpatient Behavioral Health Rehabilitation facility Pharmacy facility Physical Therapy Scene Phase: Evaluation Resuscitation Operative Critical Care Recovery Rehabilitation Target: Cosmetic Diagnostic Other Palliative Preventative Reconstructive Rehabilitative Research Therapeutic Domain (√) - continued
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