Get Az Reportable Event Record/report 2017-2025

The AZ Reportable Event Record/Report is a critical tool for documenting significant events in long-term care facilities. This guide provides clear and supportive instructions for filling out the form online, ensuring all necessary details are accurately captured.

Follow the steps to complete your report effectively.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Fill in today's date in the specified field using the format mm/dd/yyyy. Indicate whether the event was significant by selecting 'Yes' or 'No.'
3. Enter the date of the event in mm/dd/yyyy format and the time of the event, specifying whether it occurred in the AM or PM.
4. Provide the full name and address of the facility, along with the facility telephone number, state, and zip code. Include the facility license number for verification.
5. Identify the person reporting the event by providing their details including provider ID or CCN and title.
6. Select the type of incident by checking all applicable options from the list provided. Ensure all relevant incidents are accounted for.
7. List all parties notified about the occurrence. This includes law enforcement, medical professionals, and any relevant boards or authorities.
8. If the event involves allegations of abuse, neglect, or misappropriation of funds, complete the Alleged Perpetrator Information Section with the necessary details.
9. Provide credentialing or licensure information as required, filling in any applicable certifications and the resident's information including their name, date of admission, date of birth, and exact location of the incident.
10. Compose a narrative detailing the event. This should encompass timeframes, relevant risk factors, and any prior interventions. Address specific questions provided in the narrative section.
11. Document any interventions implemented following the incident or event, including any actions taken to ensure resident safety.
12. Complete the Facility Investigation Report section as needed, ensuring each witness has their statement recorded on separate sheets if necessary.
13. Review all filled sections for accuracy and completeness. After verifying the information, save your changes, download the report if needed, or print it for submission.

Complete the AZ Reportable Event Record/Report online today to ensure timely and thorough documentation.