The Clinical Incident Reporting Form should be completed in situations where clinic outcomes of treatment are less than desirable. Supervising faculty should assist students in completing this form and signing it prior to submission. The Office of Quality Assurance and Compliance will keep this document on file at the College of Dentistry.
The Clinical Incident Reporting form is available in all clinics in the Clinic Binder. The “official” Clinic Binder is now available in axiUm. The location is axiUm/Links/Clinic Binder.
INSTRUCTIONS FOR COMPLETING THE CLINICAL INCIDENT REPORTING FORM
A student, practitioner, or faculty member shall complete this report when an incident that causes a negative response by a patient or family member occurs or is suspected to occur. All sections should be completed as applicable.
Demographic information: Please include ALL information regarding the patient record, those people involved, and the clinic in which the incident took place. Indicate if informed consent was obtained in written or verbal form.
I. Occurrence: Include a concise description of the incident and the names of any other individuals who witnessed the incident; if additional space is needed, the back of the form may be used. All written reports should only contain facts and should not include opinions, conclusions, or judgments.
II. Discovery: Indicate all individuals that acknowledged the incident, including the patient, family members of the patient, or a person escorting the patient. Provide a description of the information given to this person(s) and indicate whether a prognosis and any follow-up care were discussed. Be certain to indicate the patient’s understanding of the explanation for the cause of the incident and their satisfaction with that explanation. If a resolution was proposed to the patient include a description of the terms discussed.
III. Resolution: Indicate who INITIALLY offered reimbursement to the patient. Supervising clinic faculty should indicate who requests reimbursement for approval by Clinic Operations (either Supervising Faculty or the Department Chair). Be certain to indicate in the “Patient’s Comments” any questions or remarks made by the patient in response to the terms of reimbursement. Additionally, a description of any arrangements such as remakes, special arrangements for treatment in other clinics, etc. should be included in the section on “Arrangements Made…”. “Additional Comments” should include a brief discussion of the patient's concerns regarding how the situation was managed and any remarks that may be the result of a conversation with a family member or person escorting the patient.
BOTH FACULTY AND STUDENT OR PRACTITIONER MUST SIGN THE REPORT AND DATE OF COMPLETION
A copy of the treatment progress notes from the patient’s dental chart must be attached to the form and returned in an envelope marked CONFIDENTIAL to the Office of Quality Assurance and Compliance, in Room 238.
This form will be available in all clinic faculty offices and should be completed immediately following the incident.
Upon receipt, the Office of Quality Assurance and Compliance will review this form with the appropriate departmental faculty to determine a course of action and prevent future incident recurrence. Students and faculty should refer any further communication from the patient regarding the incident to the Director of Patient Relations. This report shall be shared with the OUHSC Office of Legal Counsel and the OUHSC Campus Risk Management Office.
