State Specific Information Incident Report (Montana)

Montana

Description of Incident Reporter Code O Employee O Consumer O TCM O DDP O Other If Other

Supervisor Review Type of incident O Aspiration/Choking O Discovery of Contraband O Use of PRN Medication (Primary) O Use of Exclusion Time Out O Use of Seclusion Time Out O Rights Violation O Seizure O Self Injurious Behavior (SIB) O Injestion of Harmful Substance O Abuse: Physical Injury O Abuse: Mental Injury O Abuse: Exploitation O Abuse: Neglect O Abuse: Sexual Abuse O Mistreatment

Type of incident O Aspiration/Choking O Death O Discovery of Contraband O Hospitalization (Secondary) O Medication Error O Missing Person O Injury O Property Damage O Use of Mechanical Restraint O Use of Physical Restraint O Use of PRN Medication O Use of Exclusion Time Out O Use of Seclusion Time Out O Rights Violation O Seizure O Injestion of Harmful Substance O Law Enforcement Involvement O Self Injurious Behavior (SIB) O Suicide Threat/Attempt O Abuse: Exploitation O Abuse: Physical Injury O Abuse: Mental Injury O Abuse: Neglect O Abuse: Sexual Abuse O Mistreatment

Cause of Incident (Primary) Consumer Action O Fall O Ingested O Medical Condition O Accident O Physical Aggression O Provoked O Seizure O Self-Injurious Behavior O Other

Other Consumer Action O Accident O Physical Aggression O Provoked O Other

Initials

Employee Action O Accident O Suspected A/N/M O Other Employee Action

Employee Name

Other Person Action O Family Member O Individual in the Community O Visitor

Person Name

Hazardous Condition of Action O Equipment O Physical Environment O Unknown/Undetermined Property

SIGNATURE………………………………………NAME………………………………………………………DATE……………………TIME…………………am/pm Note:- Required fields are marked with an asterisk (*) © Copyright Therap Services, LLC. 2003 - 2006, All Rights Reserved For Version 6.2 Page 1 of 4

Montana

Cause of Incident (Secondary) Consumer Action O Fall O Ingested O Medical Condition O Accident O Physical Aggression O Provoked O Seizure O Self-Injurious Behavior O Other

Other Consumer Action O Accident O Physical Aggression O Provoked O Other

Initials

Employee Action O Accident O Suspected A/N/M O Other Employee Action

Employee Name

Other Person Action O Family Member O Individual in the Community O Visitor

Person Name

Hazardous Condition of Action O Equipment O Physical Environment O Unknown/Undetermined Property

Secondary Location O Home-Inside–Bathroom O Home-Inside–Bedroom O Home-Inside–Hallway O Home-Inside-Kitchen/Dining O Home-Inside-Living Room O Home-Inside–Other O Home–Outside O Vehicle O Natural Home (Residence) O Natural Home(visit) O Day Program O Work O School O Community–Supervised O Community–Unsupervised O Unknown

Actions Taken O Reportable O Critical O Elder Abuse Act - Attach IR Addendum

Medical/Injury Assessment/Treatment Assessment O X-ray O Abdominal Thrust O CPR O Hospital Emergency Room O Hospitalization-Medical O Hospitalization - Psychiatric

Type of Injury O Cut/Laceration w/sutures O Pregnancy O Reddened Area O STD (Primary) O Soft Tissue Swelling O Other If Other

Type of Injury O Abrasion/Scrape/Scratch O Airway Obstruction O Allergic Reaction O Bite/Sting (Secondary) O Burn/Blister O Bruise/Contusion O Concussion O Cut/Laceration O Cut/Laceration w/sutures O Dislocation O Fracture O Hematoma O Infection O Lesion O Loss of Consciousness O Puncture O Pregnancy O Reddened Area O Soft Tissue Swelling O Sprain O Strain O STD O Sunburn O Frostbite O Other If Other

Montana

Cause of Injury O Animal O Chemical Burn O Choke on Food Object O Drug/Alcohol use

(Primary) O Equipment Problem O Escort O Grab/Hold O Hair Pull O Head Bang O Heat/Cold O Hit/Slap O Human Bite/Scratch O Kick O Medication Error O Medication Use O Pinched O Provoked O Push/Shove O Restraint Chemical O Restraint Manual O Restraint Mechanical O Rub/Friction O Sexual Trauma O Sharp Object O Thrown Object O Twisting O Other If Other

Cause of Injury O Animal O Bumped/Stubbed O Chemical Burn O Choke on Food Object (Secondary) O Drug/Alcohol use O Environmental Hazard O Equipment Problem O Escort O Fall/Slip/Trip O Food/Drink O Grab/Hold O Hair Pull O Head Bang O Insect O Heat/Cold O Hit/Slap O Human Bite/Scratch O Injestion O Kick O Provoked O Medication Error O Medication Use O Pinched O Push/Shove O Rub/Friction O Restraint Chemical O Restraint Manual O Restraint Mechanical O Sharp Object

O Self Injurious Behavior O Sexual Trauma/Injury O Thrown Object O Twisting O Vehicle Accident O Undetermined O Other If Other

Primary Injury O Scalp O Face O Eye O Nose O Lips O Cheek O Mouth O Teeth

Location(Primary) O Tongue O Throat O Chin O Neck O Collarbone O Shoulder O Upper Arm O Elbow O Forearm O Wrist O Hand O Finger O Thumb O Chest O Back O Breast O Ribs O Abdomen O Buttocks O Anus O Genitalia O Thigh O Knee O Shin O Calf O Ankle O Heel O Instep O Toes O Ear O Hip

(Secondary) O Scalp O Face O Eye O Nose O Lips O Cheek O Mouth O Teeth O Tongue O Throat O Chin O Neck O Collarbone O Shoulder O Upper Arm O Elbow O Forearm O Wrist O Hand O Finger O Thumb O Chest O Back O Breast O Ribs O Abdomen O Buttocks O Anus O Genitalia O Thigh O Knee O Shin O Calf O Ankle O Heel O Instep O Toes O Ear O Hip

Side of Body (Primary) O Front O Back O Both Sides O Center O Left O Right

O Lower O Upper O Internal

(Secondary) O Front O Back O Both Sides O Center O Left O Right O Lower O Upper O Internal

Describe Assessment/Tx Given

Witness Witness 1

Witness 2

Witness 3