COVID-19 Products

COVID-19 Incident Report for Patient or Visitor

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COVID-19 Incident Report for Patient/Visitor Exposure RLDatix Page 2 of 8 March 20, 2020 Revision 1 CONTENTS Introduction............................................................................................................................................................ 3 Form Preview ......................................................................................................................................................... 3 Patient Demographics .......................................................................................................................................... 6 Last Name:........................................................................................................................................................... 6 First Name: .......................................................................................................................................................... 6 Patient ID/Record #/MRN: ................................................................................................................................... 6 Age: ...................................................................................................................................................................... 6 Sex: ...................................................................................................................................................................... 6 Address: ............................................................................................................................................................... 6 Contact details: .................................................................................................................................................... 6 Was patient previously in another healthcare facility? ........................................................................................ 6 If yes, name of facility: ......................................................................................................................................... 6 Type of facility: ..................................................................................................................................................... 6 Type of Patient: .................................................................................................................................................... 6 Location ............................................................................................................................................................... 6 Time and Date of potential exposure: .................................................................................................................. 6 Primary reason for visit/hospitalization: ............................................................................................................... 6 Attending Physician Name:.................................................................................................................................. 6 Care Team notified of potential exposure: ........................................................................................................... 6 COVID-19 Patient Details ...................................................................................................................................... 7 Date of employee exposure ................................................................................................................................. 7 Does the patient provide history of living in the same household environment with a confirmed COVID-19 patient? ................................................................................................................................................................ 7 Does the patient have history of traveling in proximity (within 1 meter) with a confirmed COVID-19 patient in any kind of conveyance? ..................................................................................................................................... 7 Was the patient in close proximity contact (within 1 meter) with a confirmed COVID-19 patient in the health care facility? ......................................................................................................................................................... 7 Was the patient present when any aerosol generating procedures (AGP) was performed? .............................. 7 If yes, what type of AGP procedure? ................................................................................................................... 7 Did the patient have direct contact with the environment where the confirmed COVID-19 patient was cared for? E.g. bed, linen, medical equipment, bathroom, personal effects etc. ......................................................... 8 During the period of interaction with a COVID-19 infected patient, did the patient have any episode of exposure with biological fluid/respiratory secretions? ......................................................................................... 8 If yes, which type of exposure? ........................................................................................................................... 8 Exposure event description: ................................................................................................................................ 8

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