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Client Incident Report - Home & Community Services
Phone: (248) 395-3777, Fax: (248) 395-3370,
www.hchs.com
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28000 Woodward Ave., Royal Oak, MI 48067
Client Involved
First Name:
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Last Name:
*
Date of Incident:
*
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Time of Incident (in military time):
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Age:
*
Employee Present at time of incident?
*
Yes
No
Employee Information
First Name:
*
Last Name:
*
Title:
*
Location of Incident:
*
Property/Equipment contributed to incident?
*
Yes
No
Describe property or equipment involved?
*
Type of Incident:
*
Abrasion
Burn
Choking
Contusion
Dislodging of Feeding Tube
Laceration
Medication Error
Respiratory Distress
Slip/Fall
Wound
Other
Was this a decanulation?
*
Yes
No
Please explain
Description of incident by person involved (what happened, why it happened, what the causes were, etc. If an injury, state part of body injured. If property damaged, describe damage.):
*
Was it necessary to contact a physician?
*
Yes
No
Please indicate with whom you spoke with an a brief summary of the conversation:
*
Was the client seen by a physician?
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Yes
No
Physician's name or name of hospital/Emergency Department:
*
Were new orders given?
*
Yes
No
New orders:
*
Result of visit:
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Was a HealthCall supervisor notified?
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Yes
No
Name of Supervisor Notified:
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Time:
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Instructions from Supervisor:
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Narrative:
First Name of person filling out report:
*
Last name of person filling out report:
*
Title of person filling out report:
*
Date of Report:
*
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v3 - 05.01.2023
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