Follow the steps to effectively complete the incident report form.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Fill in the reporting information section. Begin by indicating the reportable incident type by checking the appropriate box and providing the date and time of the incident.
3. Provide the facility information, including the facility license number, provider number, name, address, contact person, telephone number, email address, and fax number.
4. Craft a summary of the incident. Include what occurred, who was involved (e.g., personnel, patients), and the actions taken at the time of the incident. Ensure clarity and detail.
5. Write a narrative report, detailing your investigation of the incident. Describe how it was handled and the measures you will implement to prevent similar occurrences in the future.
6. List the actions you will take as a result of the incident in the action section. Check all applicable options, including staff education and policy revisions.
7. Complete the patient information section if the incident involved a patient. Include their name, date of birth, dialysis start date, and current condition.
8. Fill out the treatment information, specifying the service type and access type, as well as the patient's vital statistics like blood pressure and weight.
9. In the patient transfer section, if applicable, enter the name of the facility to which the patient was transferred and the date of the transfer. Include additional required documentation.
10. Ensure the supervising nurse prints their name, title, signs, and dates the incident report. Submit the completed form via fax or mail to the specified address.
11. Once all information is entered and verified, save any changes, and you can download, print, or share the form as needed.

Complete your TX HHS ESRD Facility Incident Report Form online to ensure timely reporting and follow-up.