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 3 of 8 March 20, 2020 Revision 1 Introduction RLDatix has prepared this sample Patient or Visitor exposure form to help our customers track COVID-19 related events. This form represents a compilation of common fields that we have seen on various forms available in the public domain. This form is not intended to be specific to any particular jurisdiction, and as such, customers are encouraged to view this form as a starting template and make any necessary modifications to comply to local reporting requirements. Using the form design functionality within the RLDatix software, customers can choose to build this form in their current instance of the RLDatix software, or they can take elements from this form and modify an existing form currently in place for staff/employee event tracking. Should a customer need assistance building/modifying a form, please submit a support ticket to RLDatix and our customer support teams will be happy to assist. Form Preview Patient Demographics Last name: PT. ID e.g. Record # or MRN First name: Age: Sex: ☐Male ☐Female ☐Prefer not to answer Address: Contact details: Was patient previously in another healthcare facility? ☐Yes ☐No ☐Unknown If yes, name of facility: Type of facility: ☐Hospital ☐Outpatient clinic ☐Primary health center ☐Rehabilitation care center ☐Long Term care center ☐Palliative care center ☐Home care for mild cases ☐Other, specify: Type of Patient: ☐In Pt. ☐Out Pt. Location Use regular location hierarchy Time & Date of potential exposure Date (DD/MM/YYYY): ___/___/______ Time: ☐Not known Primary reason for visit/hospitalization Description: Attending Physician Name: Care Team notified of potential exposure: ☐Yes ☐No ☐Unknown Date (DD/MM/YYYY): ___/___/______ Time: COVID-19 Patient Details

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