Documentation Event
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Documentation 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
Section 2: Occurrence Details
Event / Incident Reason
*
No H&P
No Consent
Missing Documentation in EMR
Legibility
Unapproved Abbreviations
HIPAA / disclosure error
Missing Forms
Type of HIPAA Error
*
Select
Unsecured computer/screen
Unauthorized emergency contact disclosure
Improper visitor/phone ID verification
Mismatched patient record scanning
Inappropriate text messaging use
Incorrect discharge paperwork
Other
Other HIPPA / disclosure Error
*
Which consent is missing?
*
Which forms are missing?
*
Patient name
*
DOB
FIN number
Description of event
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