COVID-19 Products

COVID-19 Incident Report for Patient or Visitor

Issue link: https://resources.rldatix.com/i/1223403

Contents of this Issue

Navigation

Page 5 of 7

COVID-19 Incident Report for Patient/Visitor Exposure RLDatix Page 6 of 8 March 20, 2020 Revision 1 Patient Demographics Last Name: First Name: Patient ID/Record #/MRN: 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 Patient • Out Patient Location Time and Date of potential exposure: • (DD/MM/YYYY): • Time: Primary reason for visit/hospitalization: Attending Physician Name: Care Team notified of potential exposure: • Yes • No • Unknown

Articles in this issue

view archives of COVID-19 Products - COVID-19 Incident Report for Patient or Visitor