Patient Incident Report Form

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A patient incident report allows medical staff to document an accident or unexpected event involving a patient. It’s often used to report falls, adverse drug reactions, and treatment errors. By recording what happened along with key facts (e.g., location, time, witnesses), the report ensures that the situation can be investigated, addressed, and prevented in the future.

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Patient Incident Report Form

Last updated September 23rd, 2025

A patient incident report allows medical staff to document an accident or unexpected event involving a patient. It’s often used to report falls, adverse drug reactions, and treatment errors. By recording what happened along with key facts (e.g., location, time, witnesses), the report ensures that the situation can be investigated, addressed, and prevented in the future.

What to Include

  • Staff Identification – Name of the nurse or other individual completing the report.
  • Patient Details – Name of the person involved and their hospital or patient ID number.
  • Incident Details – Date, time, location, and a clear explanation of the incident.
  • Injuries and Damage – Specific injuries and a list of any property damage.
  • Follow-up Measures – Actions taken by the medical facility to address the issue.

Sentinel Event Reporting

Some states require healthcare facilities to report sentinel events to the health department or licensing authority. While there is no federal statute defining a “sentinel event,” it is generally understood as an incident resulting in death, severe harm, or permanent harm.[1]

If a sentinel event occurs, facilities should contact their state health department to confirm whether a formal report is required.

Sample

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PATIENT INCIDENT REPORT FORM

INDIVIDUAL FILING REPORT

Full Name: [FULL NAME] Title/Role: [TITLE/ROLE (E.G., DENTAL ASSISTANT)]

Signature:                                                           Date: [MM/DD/YYYY]

PATIENT INVOLVED

Full Name: [FULL NAME] Date of Birth: [DATE] Patient ID No.: [PATIENT ID NO.]
Address: [ADDRESS] Sex: ☐ Male ☐ Female ☐ Other Phone: [PHONE] E-Mail: [EMAIL]

INCIDENT DETAILS

Date of Incident: [DATE OF INCIDENT]      Time: [TIME] ☐ AM ☐ PM

Location: [LOCATION]

Incident Type: ☐ Accident ☐ Injury ☐ Illness ☐ Self-Harm ☐ Medication or Procedure Error
☐ Behavior ☐ Loss or Theft ☐ Damage ☐ Other: [OTHER]

Describe the Incident: [DESCRIBE THE INCIDENT]

RESPONDING ACTIONS

Describe the actions taken in response to the incident: [DESCRIBE RESPONSE]

INJURIES

Was anyone injured? ☐ Yes ☐ No
If yes, describe the injuries: [INJURY DESCRIPTION]

Was there any exposure to body fluids? ☐ Yes ☐ No
If yes, describe exposure and action taken: [EXPOSURE DESCRIPTION AND RESPONSE]

Was there any damage to equipment or property? ☐ Yes ☐ No
If yes, describe the damage: [DAMAGE DESCRIPTION]

WITNESSES

Were there witnesses to the incident? ☐ Yes ☐ No

If yes, enter the witnesses’ names and contact info:

  1. Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL]
  2. Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL]
  3. Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL]

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