Adverse event and incident report

Medical IV Hydration Business | PublicProof Academy working document

Non-editable educational sample of record categories. Not an approved clinical form or treatment protocol. A qualified professional must review suitability before use in their own secure system.

Business

State or jurisdiction

Prepared on

Owner

Official source saved

Next review

What happened

Date, time and location (clinic or mobile address)
Patient chart ID and the order being administered
Product and lot numbers involved
Description of the event in plain clinical language
Time from start of infusion to first symptom

What was done

Infusion stopped at (time)
Interventions given, with drug, dose, route and time
911 called at (time) / transported to
Prescriber notified at (time) and by what method
Patient condition at handoff or discharge
Follow-up contact made on (date)

Who was notified

Medical director notified (date/time)
Professional liability carrier notified (date)
State board report required? Confirm the requirement and record the answer
FDA MedWatch report considered for a product problem
Supplier or 503B facility notified if the product is suspected

What changes because of this

Protocol change made (describe)
Training or competency action taken
Screening exclusion added
Equipment or emergency kit change
Date the change was communicated to all staff

Use rule: Education and organization only. Record the agency, official source, checked date, cost, proof saved and responsible person for every consequential requirement. Unknown means stop and confirm. Example rows are labeled EXAMPLE and are not your data.