Nevada Health Centers, Inc

Investigation Report 1 Check all that apply:  Risk Management  Incident  Patient Complaint  Pt Termination . Request

2 Choose one:  Operational  . Clinical/Medical

3 Site Where Incident Occurred: . 4 Investigator Name(s): Incident Date: / / . 5 Patient Name (if applicable): D.O.B. / / . Patient Phone Number:

6 Brief Summary of Incident/Complaint (May attached witness statements - Use back of this page if Needed): .

Type of Incident:  Sharps exposure  Fall  Patient Complaint 7  Pharmacy Error  Billing Problem  Lab Problem  Misunderstanding  Complaint  Confidentiality Breach  Disruptive Patient  Other

8 Cause:  Human Error  Misunderstanding  Equipment Failure .  Systems Failure  Accident  Failure to follow P&P  Confidentiality Breach  Other

9 Action (Use back of this page if needed):  Procedure Change  Employee Education  Staff Corrective Action  Site Training  No Action  Other

 Team Requesting Patient Termination 10 .  Approved by:  Denied by:

INVESTIGATION CYCLE 11 Operational Incident/Complaint Clinical/Medical Incident/Complaint Clinic Coord Signature: Provider Signature: Provider Signature: Clinic Coord Signature: ROD Signature: DOO/DDO Signature: RCD Signature: CEO/CFO Signature: CMO/CEO Signature:

12  Date Entered into Database: / / Initials: Revised 08/08/05 MEC Review Date: / / BOD / RM Review Date: / / 13

14 Case Closed – Initials Date / /

Revised 08/08/05