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Event Entry
* Event Category
* Event Type:
* Event Location:
* Reporting Department:
Event Information
* Event Date/Time:        * Discovered Date/Time:   
       * Did event involve a patient? No Yes
Patient Information
* First Name:    * Last Name:     DOB:    Age:  
Gender:  Male  Female                    * Patient Account #:   
Family/Friend/Companion Aware:  No Yes Unknown
    * Was there a patient injury?:  No Yes Unknown
Provider Notified
     No Yes       Name:        Notified Date/Time: 
Additional Event Information
Required - except for HIPAA and Compliance
Reported By:         Witness 1:         Witness 2: 
* Tell the Story: (Who, What, Where, Why or How)

* Was this corrected at time of the occurrance? If so, How?

For Quality and Risk Questions Call: Jennifer Cano 854-2241 Ext. 2099 OR Cathy Harshbarger 854-2241 Ext. 2132