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    Assg Incidentreportform 20180122 Ah102121

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    api-415690991
    Nurse Brown filled out an incident report form to report an incident where she was injured by a patient, Mrs. Lowry. [The form collects information about the person involved, the incident details including date, time, location, description, witnesses, and any resulting injuries.] Nurse Brown sprained her knee after Mrs. Lowry hit her with a cane. The report was submitted to the President's Office as required within 24 hours of the incident.

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    Assg Incidentreportform 20180122 Ah102121

    Uploaded by

    api-415690991
    31 views2 pages
    Nurse Brown filled out an incident report form to report an incident where she was injured by a patient, Mrs. Lowry. [The form collects information about the person involved, the incident details including date, time, location, description, witnesses, and any resulting injuries.] Nurse Brown sprained her knee after Mrs. Lowry hit her with a cane. The report was submitted to the President's Office as required within 24 hours of the incident.

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    assg incidentreportform 20180122 ah102121

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    Nurse Brown filled out an incident report form to report an incident where she was injured by a patient, Mrs. Lowry. [The form collects information about the person involved, the incident details including date, time, location, description, witnesses, and any resulting injuries.] Nurse Brown sprained her knee after Mrs. Lowry hit her with a cane. The report was submitted to the President's Office as required within 24 hours of the incident.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    31 views2 pages

    Assg Incidentreportform 20180122 Ah102121

    Uploaded by

    api-415690991
    Nurse Brown filled out an incident report form to report an incident where she was injured by a patient, Mrs. Lowry. [The form collects information about the person involved, the incident details including date, time, location, description, witnesses, and any resulting injuries.] Nurse Brown sprained her knee after Mrs. Lowry hit her with a cane. The report was submitted to the President's Office as required within 24 hours of the incident.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    Incident Report Form

    Use this form to report accidents, injuries, medical situations, or student behavior incidents. (Incidents involving a crime or
    traffic incident should be reported directly to the Campus Public Safety office.) If possible, the report should be completed
    within 24 hours of the event. Submit completed forms to the President’s Office.

    INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT


    Full Name Cora lee Brown
    Home Address 1234 brown Street, Lexington Nc 37468
    D Student D Employee D Visitor D Vendor
    Phone Numbers Home Cell Work

    INFORMATION ABOUT THE INCIDENT


    Date of Incident Time Police Notified  Yes  No
    04/08/2018 8:00AM
    Location of Incident : The room of mrs. Lowry

    Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
    (attached additional sheets if necessary)
    Nurse Brown entered the room and seen that mrs. Lowry was struggling. She offered to help and mrs. Lowry hit her in the
    leg with her cane.

    Were there any witnesses to the incident?  Yes  No


    If yes, attach separate sheet with names, addresses, and phone numbers.
    Was the individual injured? If so, describe the injury (laceration, sprain, etc.), the part of body injured, and any other
    information known about the resulting injury(ies). Nurse Brown was injured with a sprained knee

    Was medical treatment provided?  Yes  No  Refused


    If yes, where was treatment provided:  on site  Urgent Care  Emergency Room  Other

    REPORTER INFORMATION
    Individual Submitting Report (print name) Cora Brown

    Signature Cora Brown

    Date Report Completed 04/08/2018

    FOR OFFICE USE ONLY

    Report Received by Date _


    FOR OFFICE USE ONLY

    Document any follow-up action taken after receipt of the incident report.

    Date Action Taken By Whom


    04/08/18 Director of facility went in and talked to Lowry Director

    04/09/18 Director assigned only two nurses for Lowry Director

    - I chose this assignment because knowing how to fill out this incident report is a part of the everyday duties of
    a medical assistant. If you don’t know how to fill out a report this could cause big problems in your job. If you
    get hurt on the job you only have 24 hours to get this form filled out and to the right person.

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