AMA Incident Event
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Section 1: Initiator Details
Initiator name
*
Initiator's email
Initiator department
*
Select
Admitting
Business Office
Case Management
Dietary
HIM
Human Resources
Infection Control
Lab
MAT
Medstaff
Medsurg
Pharmacy
Plant Ops
Psych
Radiology
Respiratory
Risk
Security
Social Services
Surgery
UR
Warehouse
IT
RHC Arvin
RHC Shafter
RHC Wasco
Wound Care
ICU
Other
Date of occurrence
*
Time of occurrence
*
Other Initiator Department
*
Location of occurrence
*
Select
Admitting
Business Office
Case Management
Dietary
HIM
Human Resources
Infection Control
Lab
MAT
Medstaff
Medsurg
Pharmacy
Plant Ops
Psych
Radiology
Respiratory
Risk
Security
Social Services
Surgery
UR
Warehouse
IT
RHC Arvin
RHC Shafter
RHC Wasco
Wound Care
ICU
Other
Other
*
Room #
Additional details
Occurrence related to
Patient Name
*
Patient DOB
*
Patient FIN number
*
Section 2: Occurrence Details
Is the patient in the right decision making compacity ?
*
Yes
No
Please provide reason why patient wants to leave
*
Released by court
*
Yes
No
Investigation
*
Yes
No
Provide Investigation detailed reasoning
*
Action Taken
*
Risk and Benefits explained
Alternative plan
Educated patient they are welcome to return
Efforts to convince pt to stay
Other
Other Action Taken
*
Patient Admission
*
Date
Time
Patient Discharge
*
Date
Time
Additional Comments
*
Family/Caregiver notified
*
Yes
No
Name
Relation
Date
Time
Reason
Physician notified
*
Yes
No
Physician name
Select
Matab Singh MD
Romona Dolan PA
William Bichai MD
Juan Sosa MD
Ravi Kapadia MD
Ruben Nieto MD
Mandeep Bagga MD
Mushtaq Ahmed MD
Oriente Esposo MD
Other
Type of physician intervention
Change Patient Care Plan
Use of Restraint
Seclusion
Patient Assessment
Close Monitoring
Medication Escalation
Other
Other Physician Name
Other Physician Intervention Type
Date
Time
Reason
Was belongings given to patient ?
*
Yes
No
N/A
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