Healthcare personnel in hospitals or medical centers ensure that they provide the needs of the patients (pertaining to the treatments or medications needed) and their individual relatives (pertaining to the answers or provision of exact details from the medical results). It goes without saying that everyone wants an accurate general information with regards to the health state or condition of the patient or their hospitalized loved ones. Therefore, one thing that could help are the patient report forms. These are used to summarize the overall findings from the diagnosis of a patient assessment, thus, making it easier to display and explain the results briefly yet comprehensively.
Generic Patient Report Form
Observational Patient Report Form
Why Patient Reports Are Needed
Patient medical reports serve as evidences that the patient has been given proper medications or treatments. Doctors or physicians are doing the best they could in order to supply the needs of each and every patient, regardless if they are in a critical condition or not. These reports are mandatory for the individual patient. This is for the reason that these are part of their health or medical history. Therefore, it is mandatory that the medical clinic, center, or hospital keeps a record of their patients.
These patient reports also help the doctors and the relatives of the patient to know what is or are behind the patients’ results of their individual health assessment. Thus, the form for patient report contains all the fields for information and exact details that are needed to be provided. In other words, the patient report forms are organized and layered which makes it easier to be filled with all the relevant information. And when all the precise information are provided, it is much easier to assess or evaluate the current state of one’s health condition.
There are further reasons or purposes why patient reports should be secured. These reports help the health assessment personnel to treat those newly discovered diseases and find more ways to treat each immediately and avoid the disperse of it to other places. These are also used as references to other medical issues of a different patient, due to the fact that these could help the healthcare personnel to compare how treatments worked in reviving a patient.
Yet, these medical reports or records should not be shown to other unauthorized people. The reason for this is because these files are confidential, and the only people who could have access to these are those who are authorized, unless the patient or the owner of the records gives his or her consent for the information to be released to certain people or to the public. Otherwise, the clinic, center, or hospital are held accountable for such infringement with regards to the confidential information.
These patient reports are indeed mandatory. The reason is simply because these also serve as the doctor’s basis or references in explaining the condition of the patient to his or her relatives. As one would expect that everyone is anxious to know if the patient is recovering from the accident report or incident that he or she has suffered. Further provided for you in this article are few samples for patient report forms. These could be downloaded and utilized for your convenience. Take time to browse over these report forms, as you find what you think you need.
Accident and Patient Report Form
Patient Assessment Report Form
Pre-Hospital Patient Report Form
Patient Report or Referral Form
Patient Death Reporting Form
What to Do When a Person Is Injured
Here are some tips or guide on what to do when you found out that a person is injured or had suffered from an incident or accident. Refer to these following printable statements and put yourself in the shoes of the different people who are often involved in this kind of situation.
As a witness. The first thing that you should do when you witness an incident or accident is to report what has happened. If response has not arrived yet and the situation is critical, check the vital signs of the injured person. Determine whether he or she is conscious, responsive or not. Do not panic, since by doing so, you will just worsen the situation.
Be professional and do what you are supposed to. If in case that you do not have a first aid experience, contact someone who has. Do not act like you know what to do. If immediate response is needed, call for some immediate help from the hospital release or the police. Do not ask help from those people who do not have the capabilities to help. When help arrives or everything is settled (at least for the moment), explain or report to the authorized personnel regarding the occurrence. Give full details with the use of incident or accident report form. Fill out the essential information that are needed in order for the authorized people to have an effective investigation of what has occurred.
As the relative. If in case that you happened to be a relative of the injured person, the first thing to do is to calm down. Go straight to the hospital where the patient is brought. Call your other relatives or the family member of the injured person. And the best thing to do when you have arrived at the location is to wait. Wait for the medical results and answers to your questions from the authorized physician. You might be asked about the patient’s medical history and other relevant information.
As the investigator, police, or any help. Clear or secure the area where the incident or accident has taken place. This becomes the crime scene for complaint investigation. Look for witnesses and list down all notes from the interviews. Make sure that all your interview questions are relevant to what has happened and ensure that these lead you to the information that you are looking for. Do not rely much on those interviews. It is better that you inspect and look for evidences to see if witnesses’ statements are connected. Also make sure that all information with regards to these situation are secured while you still are looking for more answers and proofs.
As the healthcare personnel or doctor. Make sure that the patient is examined in every aspects or areas. Do not be so reckless when it comes to the medical information of your patient. Supply the needs and perform the appropriate tests that are needed to assess the condition of the patient. Fill out a medical report form in order to indicate all the laboratory tests that you perform.
Patient’s Status Report Form
Patient’s Condition Report Form
Patient’s Concern Report Form
Patient Complaint Report Form
Patient’s Adverse Event Report Form
Request for Patient’s Medical Report Form
The Parts of Patient Report Forms
In completing the patient report forms, below are the following important or essential information that should be provided. Otherwise, results from medical assessments cannot be given due to deficiency of relevant information.
- The patient’s personal information
- The patient’s full name
- The date of birth
- The gender
- The race or nationality
- The residential address
- The contact information
- The patient’s social security number
- The medical assessment information
- The patient’s attending physician or doctor
- The date and time when the patient was admitted or hospitalized
- The type of injuries or health problem conditions
- The patient’s medical diagnosis
- The symptoms of current condition
- The level of consciousness
- The vital signs and details
- The details of the medical treatments given
- The regular medications
- The specification of the medicines given
- The side effects of the medications
- The patient’s past medical history
- The outcome of the illness or injuries
- The result from medications or treatments
- Other additional information relevant to the case
- Other additional information or attachments such as the laboratory results or autopsy records
- The doctor or physician’s information
- The identification number
- The full name
- The address
- The contact number
- The patient report information
- The date ad time when reported
- The patient handover (whether by land or air ambulance)
- The consent for medical release of information
- The patient’s, parent’s, or guardian’s signature
- The patient’s medical referral information
- The physician’s name
- The hospital name and address
- The physician’s contact number
Other information that are needed to be secured are those information from the incident or accident. Thus, here below are the essential details to be provided using an accident or incident report form.
- The accident or incident information
- The date and time of when the it happened
- The exact place or location of where it happened
- The brief description of what happened
- The number of people affected and involved
- The contributing factors to the accident
- The eyewitness’s information
- The eyewitness’s full name
- The contact information
- The relationship to the patient
- The eyewitness’s statement
- The brief description of eyewitness’s actions
Upon supplying all those information that are needed, the investigators conduct further assessment. They ask more questions in order to thoroughly analyze what has happened. This further assessment is conducted while the patient undergoes the medical health assessment. If in any cases that the patient is not satisfied with the treatments provided to him or her, he or she could file a patient complaint.
In a patient complaint, the relevant information that are needed are as follows:
- The description of the situation
- The effect on privacy
- The witnesses if there are any (the name and contact information must be provided)
- The solutions that the patient believes to resolve the complaint
- The summary of the investigation
- The follow-up and corrective actions taken
- The date of when the complaint form was submitted
- The date of when the report is received
- The date of when the complaint is resolved
By providing all these important details, exact and accurate medical reports are given. And with the patient complaints, the doctors, hospital, or medical centers will be able to improve their health care facilities. Technically, to sum all these up, these patient report forms are mandatory to be filled out. This is for the reason that these contain relevant personal information that could help determine the current state or condition of one’s patient. These forms provided for you in this article could serve as your references to better understand what these forms are used for. You may also download which form/s are convenient for you to use.
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