* = Required Information
Today's Date :
*
Name of Client
*
Site/Program
*
Name of Medication or Treatment:
*
Date discrepancy occurred:
Time discrepancy occurred:
*
AM
PM
Date discrepancy was discovered:
*
Time discrepancy was discovered:
*
AM
PM
Type of Discrepancy (Check all that apply):
Medication/Treatment not given
Incorrect dose given
Medicaton /Treatment given to wrong client
Medication/Treatment given via wrong route
Medication/Treatment given at wrong time
Medication Treatment given on wrong date
Missing/incorrect documentation
Describe the discrepancy:
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Was the nurse notified?
*
Yes
No
Notified on what date:
Was a physician notified?
*
Yes
No
If yes, name of physician notified:
Action Taken:
Be sure to include ALL instructions from nurse or physician as well as any follow up needed. This must also be documented in Health Progress Notes and communicated with all other program staff.
Staff who discovered discrepancy:
*
Name of staff responsible for discrepancy:
*
Additional comments:
Lead Name:
*
Date Signed by PD
Full Name
*
Submit