Healthcare Boo Boo Report

HEALTHCARE BOO BOO REPORT

Patient Name:    Date of Birth:

Patient Information

Insurance Information

Medical History (relevant to incident)

Incident Details

Date of Incident:    Time of Incident:

Head    Face    Eye    Arm/Hand    Leg/Foot    Torso    Other:

Injury Assessment

Observable bleeding: Yes No    Bruising: Yes No

Swelling: Yes No    Pain level (0-10):

Severity assessed by staff: Minor Moderate Severe

Immediate Treatment / Disposition

Cleansed wound    Ice applied    Bandaged/dressings applied    Pressure applied to control bleeding

Referred for further care: Yes No    If yes, facility / provider:

Parent / Guardian Notification

Parent/Guardian notified: Yes No

Notification method:    Time notified:

Follow-up / Additional Instructions

Follow-up required: Yes No

Authorization, Certification, and Privacy Acknowledgment

I certify that the information on this form is accurate to the best of my knowledge and that the described treatment was provided as documented. I authorize the release of information from this report to other healthcare providers and insurers for treatment, payment, or healthcare operations as necessary to address this injury. I understand that this report will be incorporated into the patient's medical record.

I acknowledge receipt of the facility's privacy practices and understand my rights regarding the use and disclosure of protected health information in relation to this incident.

Authorization for treatment if patient is a minor: I authorize medical care deemed necessary for the minor named above until the authorization expiration date. Authorization expiration date:

HIPAA Privacy Acknowledgment: I acknowledge receipt of privacy notice and consent to uses/disclosures described above.

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