Hospital and Ambulatory Surgical Center Fax Report Form - Massachusetts

This fillable "Hospital and Ambulatory Surgical Center Fax Report Form" is a document issued by the Massachusetts Department of Public Health specifically for Massachusetts residents.

Download the PDF by clicking the link below and complete it directly in your browser or through the Adobe Desktop application.

ADVERTISEMENT
HOSPITAL AND AMBULATORY SURGICAL CENTER
FAX REPORTING OF INCIDENTS AND ABUSE
GENERAL INSTRUCTIONS:
1. These instructions apply to reporting all hospital and ASC incidents, and suspected abuse,
neglect, mistreatment and misappropriation of patient property under the Patient Abuse Law.
2. Complete a separate blank form for each occurrence following the instructions below.
3. Use the attached tables to enter a description for those items that are marked “see table.”
4. Submit your completed report by fax to the Department immediately for (1) fires; (2) suicide; (3)
serious criminal acts; (4) pending or actual strike; (5) serious physical injury or harm to a patient
resulting from accident or unknown cause; and, (6) suspected abuse, neglect, mistreatment or
misappropriation involving nursing home, rest home, home health, homemaker and hospice
patients. Notify the Department immediately by phone at 617-753-8150 of any deaths
resulting from incidents, medication errors, abuse or neglect; and full or partial evacuation
of the facility for any reason. Submit other completed reports within seven days of the date of
the occurrence of an incident seriously affecting the health and safety of patients.
5. Fax your completed report to the Department at 617-753-8165.
LINE BY LINE INSTRUCTIONS
FROM: Please provide the name and address of the facility making the report.
DATE OF REPORT: Enter the date that you are submitting your report to the Department.
FOR ABUSE, NEGLECT, MISTREATMENT or MISAPPROPRIATION OCCURING IN
NURSING HOME, REST HOME, HOME HEALTH, HOMEMAKER OR HOSPICE SETTING,
NOT AT THE REPORTING HOSPITAL/ASC:
FACILITY/AGENCY NAME: Indicate the name of the provider at which the suspected
abuse, neglect, mistreatment or misappropriation occurred.
ADDRESS: Indicate the address (city or town, if street address is not known) of the
provider at which the suspected abuse, neglect or misappropriation occurred.
Please indicate the date and time of the occurrence. If you are not able to determine when the event
occurred, state “unknown”.
PATIENT INFORMATION:
Please provide information here regarding the patient
involved. The information reported here should reflect the patient’s condition prior to the
occurrence. If more than one patient was injured, or if one patient has injured another
HOSPITAL AND AMBULATORY SURGICAL CENTER
FAX REPORTING OF INCIDENTS AND ABUSE
GENERAL INSTRUCTIONS:
1. These instructions apply to reporting all hospital and ASC incidents, and suspected abuse,
neglect, mistreatment and misappropriation of patient property under the Patient Abuse Law.
2. Complete a separate blank form for each occurrence following the instructions below.
3. Use the attached tables to enter a description for those items that are marked “see table.”
4. Submit your completed report by fax to the Department immediately for (1) fires; (2) suicide; (3)
serious criminal acts; (4) pending or actual strike; (5) serious physical injury or harm to a patient
resulting from accident or unknown cause; and, (6) suspected abuse, neglect, mistreatment or
misappropriation involving nursing home, rest home, home health, homemaker and hospice
patients. Notify the Department immediately by phone at 617-753-8150 of any deaths
resulting from incidents, medication errors, abuse or neglect; and full or partial evacuation
of the facility for any reason. Submit other completed reports within seven days of the date of
the occurrence of an incident seriously affecting the health and safety of patients.
5. Fax your completed report to the Department at 617-753-8165.
LINE BY LINE INSTRUCTIONS
FROM: Please provide the name and address of the facility making the report.
DATE OF REPORT: Enter the date that you are submitting your report to the Department.
FOR ABUSE, NEGLECT, MISTREATMENT or MISAPPROPRIATION OCCURING IN
NURSING HOME, REST HOME, HOME HEALTH, HOMEMAKER OR HOSPICE SETTING,
NOT AT THE REPORTING HOSPITAL/ASC:
FACILITY/AGENCY NAME: Indicate the name of the provider at which the suspected
abuse, neglect, mistreatment or misappropriation occurred.
ADDRESS: Indicate the address (city or town, if street address is not known) of the
provider at which the suspected abuse, neglect or misappropriation occurred.
Please indicate the date and time of the occurrence. If you are not able to determine when the event
occurred, state “unknown”.
PATIENT INFORMATION:
Please provide information here regarding the patient
involved. The information reported here should reflect the patient’s condition prior to the
occurrence. If more than one patient was injured, or if one patient has injured another
patient, provide additional patient information under the narrative portion of the report or on
an additional page. Please indicate:
NAME: The patient’s first and last name.
AGE; SEX; ADMISSION DATE: Enter each for the named patient.
AMBULATORY STATUS: Select the term from Table #1, “Ambulatory Status”, that most
closely describes the patient’s ability to walk.
ADL STATUS: Activities of Daily Living (ADLs) such as eating, dressing or personal
grooming. Select the term from Table #2, “Patient ADL Status”, that most closely
describes the patient’s ability to perform these functions.
COGNITIVE LEVEL: Select the term from Table #3, “Patient Cognitive Status”, that best
describes the patient’s cognitive status at the time of the occurrence.
MENTALLY RETARDED/DEVELOPMENTALLY DISABLED: Indicate whether or not
the patient is mentally retarded or developmentally disabled. If the resident is either, indicate
the name of the Service Coordinator (mentally retarded) or Case Manager (developmentally
disabled) assigned to the patient, if known.
RACE/ETHNICITY: Indicate the Patient’s Race and Ethnicity. Complete the Hispanic
Indicator. The rules for coding race and ethnicity and the Hispanic Indicator are the same
as used by the Division of Health Care Finance and Policy in its inpatient discharge data
submission regulations. See the instructions in the Electronic Records Submission
Specification:
http://www.mass.gov/Eeohhs2/docs/dhcfp/g/regs/114_1_17_hdd_data_specs.doc
The details are on page 25 of this document.
DPH OCCURRENCE TYPE: For all reports, select the term from Table #4, “Occurrence
Type”, that best describes the occurrence you are reporting. You may select “Other” and
describe what happened in one or two words if none of the examples listed are applicable
to your report.
SERIOUS REPORTABLE EVENT: Indicate whether or not this is a report of a “serious
reportable event” as described in the current National Quality Forum (NQF) list of serious
reportable events (SRE). If it is an SRE, check of the type of SRE on the table on page 2.
For additional information regarding NQF see
http://www.qualityforum.org/pdf/news/prSeriousReportableEvents10-15-06.pdf
TYPE OF HARM: Select the term from Table #5, “Type of Harm”, that best describes the
harm or injury that resulted from the occurrence. You may select “Other” and describe
what happened in one or two words if none of the examples listed are applicable to your
report. Note that harm includes psychological injury as well as physical harm, and
SHOULD NOT BE DESCRIBED AS “NONE” SIMPLY BECAUSE THERE WAS NO
PHYSICAL HARM.
BODY PART AFFECTED: Use terms such as “arm”, “foot”, etc.; indicate left or right when
it applies.
PATIENT’S ACTIVITY AT TIME OF OCCURRENCE: Select the term from Table #6,
“Patient’s Activity” that best describes the patient’s activity at the time of the
occurrence. You may select “Other” and describe what happened in one or two words
if none of the examples listed are applicable to your report.
PLACE OF OCCURRENCE: Specify where the event occurred. Examples would include:
“patient’s room”, “dining room”, “shower room”, or any other short phrase that specifies
the type of setting in which the occurrence took place.
WHAT EQUIPMENT, IF ANY, WAS BEING USED AT TIME OF OCCURRENCE:
Specify if any equipment was in use, such as “Hoyer lift”, or “walker”.
ANY SAFETY PRECAUTIONS IN PLACE: Check the “yes” or “no”. If “yes”, describe
the precautions that were in place.
NARRATIVE: Describe fully what occurred. Indicate who, what, when, where, why and
how what is being reported occurred. Include information on how any person injured was
treated. If there were any unusual circumstances involved, describe these fully.
CORRECTIVE MEASURES NARRATIVE: Describe what actions have been taken in
response to the occurrence.
GENERAL INFORMATION: Please indicate your name and title, as the person preparing
this report, a phone number at which we can contact you if we need additional information,
and the date and time of the occurrence. If you are not able to determine when the event
occurred, state “unknown”.
STAFF PERSON IN CHARGE OF FACILITY AT TIME OF OCCURRENCE: Indicate
who was present and in charge at the facility (not on the unit) when the occurrence reported
happened.
NOTIFICATION: Indicate whether or not the patient’s family and physician, and police
were notified. Provide the name of the physician notified.
WITNESS INFORMATION: List the name and title for individuals who saw or heard what
occurred. Indicate if any of witnesses were directly involved in what occurred. Other
patients, visitors and volunteers should be listed as witnesses if they have direct knowledge
of what occurred.
ACCUSED INFORMATION: When reporting suspected abuse, neglect or
misappropriation, indicate the name of the accused, a phone number at which the accused
can be contacted, if the accused is a nurse, nurse aide or other licensed professional please
indicate the individual’s license or registration number. Check the appropriate block if
you are not reporting abuse, or the identity of the person(s) suspected of abuse, neglect or
misappropriation of a patient’s money or belongings is unknown. If more than one
individual is suspected, indicate on an additional sheet the other individual’s names, a
phone number at which they may be contacted, and if any person was acting as a nurse
aide, home health aide or homemaker.
REPORTING TABLES:
Table #4: Incident/Allegation Type (cont.)
Closure
Table #1: Ambulatory Status
Criminal Act
Independent
Death
Supervised
Dental Services
Ambulates with Assistance
Dietary Services
Dependent/Assist
Elopement/Missing Person
Walks with Cane/Walker
Emergency Care
Wheels Self
Epidemic/Disease
Wheelchair
Equipment Malfunction
Bedfast
Fall – Fracture
Other
Fall – Laceration
Unknown
Fall – Other
Fire
Fraud/False Billing
Table #2: Patient’s ADL Status
HCFRS Enrollment
Independent
Infection Control
Supervised
Injury – Burn
Dependent
Injury – Fracture
Requires verbal cues
Injury – Laceration
Requires physical assist
Injury – Other
Other
Laboratory Services
Unknown
Local Laws Violation (permits, etc.)
Maternal Death
Medical Records
Table #3: Patient’s Cognitive Status
Medication Incident
Misappropriation
Alert/Oriented
Confused
Missing Personal Property
Alzheimer’s
Neglect
Developmentally Delayed
Notification of Records Destruction
Dementia
Nursing Services
Comatose
Pharmacy Services
Mental Illness/Psych History
Physical Environment
Unknown
Physician Services
Other
Pressure Ulcer
Quality of Care/Treatment
Quality of Life
Table #4: Incident/Allegation Type
Rehabilitation Services
Abuse by Staff – Physical
Resident/Patient Rights
Abuse by Staff – Sexual
Resident/Patient to Resident/Patient Incident
Abuse by Staff – Verbal
Restraint
Abuse by Visitor/Resident/Other
Staff Credentialing
Abuse – Policies and Procedures
Strike/Pending Strike
Administration
Suicide/Suicide Attempt
Advocacy Office Violation
Surgical Services
Beds Out of Service
Transfer/Discharge
Blood and Transfusion Services
Unknown/Other
Change in Beds/Services
Change of Location
Change of Ownership
Choking/Aspiration Incident
Table #5: Type of Harm
Bruise/Hematoma
Burn
Care Not Provided
Confinement
Death
Decline in Condition
Dislocation
Emotional Harm/Upset
Fracture
Funds
Infection
Laceration
No Harm
Other – Please Describe
Pain
Pressure Ulcer
Property
Quality of Care
Reddened Area
Rough Handling
Skin Tear
Unknown
Unwelcome Sexual Contact/Advance
Table #6: Patient’s Activity
Ambulating
Crowded Area
Getting Out of Bed
Getting Up From Chair
Other – Please Describe
Reaching
Standing/Sitting Still
Standing
Toileting
Transfer/Assist
Unknown

Download Hospital and Ambulatory Surgical Center Fax Report Form - Massachusetts

450 times
Rate
4.6(4.6 / 5) 27 votes
ADVERTISEMENT