Get Tercap

Filling out the Tercap form is an essential process for documenting cases involving practice breakdowns in healthcare settings. This guide will help you navigate the form with step-by-step instructions tailored to assist users of various experience levels.

Follow the steps to successfully complete the Tercap form online.

1. Press the ‘Get Form’ button to obtain the Tercap form and open it for completion.
2. Enter the Tercap Case ID number in the designated field.
3. Provide the full name of the reviewer in the specified area.
4. Select the incident type from the list of options that triggered the report to the board.
5. Indicate the state board of nursing relevant to the incident.
6. Specify the date of the incident or select 'Unknown' if applicable.
7. If there were multiple patients involved, report data for the patient with the most serious harm or risk of harm.
8. Fill in the patient's age and gender, choosing 'Unknown' if necessary.
9. Indicate whether the patient's family and/or friends were present at the time of the practice breakdown.
10. Check any symptoms the patient exhibited at the time of the breakdown.
11. List no more than two diagnoses that contributed to the reported situation.
12. Select what happened to the patient from the provided options.
13. Choose the level of patient harm from the specified categories.
14. Identify the type of community in which the incident occurred.
15. Specify the type of facility or environment where the incident took place.
16. Indicate the facility size.
17. Select the medical record system utilized at the time.
18. Check any communication factors that contributed to the breakdown.
19. Identify leadership or management factors that were present.
20. Select any backup and support factors that applied.
21. Choose any environmental factors that may have contributed.
22. List health team members involved in the practice breakdown.
23. Check for any staffing issues that contributed.
24. Highlight any team-related issues that may have affected the outcome.
25. Provide the nurse's year of birth.
26. Indicate the nurse's gender.
27. Specify where the nurse received their nursing education.
28. List all degrees held by the nurse and the corresponding graduation and licensure years.
29. Select the current licensure status of the nurse.
30. Indicate whether English is the nurse's primary language.
31. Confirm if the nurse completed any continued competence activities in the last five years.
32. Select the nurse's APRN category if applicable.
33. Provide the work start and end times during the incident.
34. Specify the length of time the nurse worked for the organization where the breakdown occurred.
35. Indicate how long the nurse had worked in the specific department of the breakdown.
36. State how long the nurse had been in the specific nursing role during the incident.
37. Select the type of shift during which the incident occurred.
38. When applicable, report the days worked in a row at the time of the breakdown.
39. Specify if the nurse was working in a temporary capacity during the incident.
40. Describe the nurse's assignment at the time of the practice breakdown.
41. Provide the number of direct care patients assigned to the nurse.
42. Indicate how many staff members were being supervised by the nurse.
43. List the total number of patients the nurse was responsible for during the incident.
44. Check the nurse's perception of contributing factors to the breakdown.
45. Select supervisor or employer's perception of factors contributing to the breakdown.
46. Indicate whether there was any previous discipline history by employers.
47. Specify the outcome of the nurse's employment following the incident.
48. Indicate whether the incident involved intentional misconduct or criminal behavior.
49. Confirm if the practice breakdown involved a medication error.
50. Provide the names of drugs involved in any medication errors.
51. Select the type of medication error that occurred.
52. Indicate contributing factors to the medication error.
53. Confirm if the practice breakdown involved a documentation error.
54. If applicable, identify attentiveness factors in the practice breakdown.
55. Describe any clinical reasoning factors related to the breakdown.
56. List prevention factors relevant to the practice breakdown.
57. Document any intervention-related factors in the practice breakdown.
58. Indicate factors relating to the interpretation of authorized provider's orders.
59. Specify any factors connected to professional responsibility or patient advocacy.
60. Document the Board of Nursing outcome.

Complete your Tercap form online today to ensure accurate documentation of practice breakdown cases.