Incident Record Form

Lydian Care

Incident Record Form

To be completed by Lydian managers for any incident/accident/complaint or notifiable event. A copy of this form will be sent to the person reporting the event and to the registered manager.

Type of Report:*
Select from drop down list the type of report you are making.
Homecare or Healthcare:
Date Report Completed:*

Day
Month
Year
Time*

: Hours

Minutes
Report taken From:*
This is the staff member who reported the incident/event to you to record.
First Last
Name of person making the report:*
This is your details as the person completing the form.
First Last
Contact Details of person making the report:*

Email Address - You will receive a copy of the completed form.
Manager for area incident/event occured:*
Healthcare Site or Hospital:

The name of the hospital or private site where the incident/accident or complaint occurred within.
Was a Service User Involved?
Service User Name*
First Name Last Name
Service User Address*
Street Address Address Line 2 City Postcode
Gender:
- Male
- Female
Date Of Birth:

Day
Month
Year
Contact Number:*
Was a Member of Lydian Staff Involved?*
Staff Members Name:*
First Name Last Name
Was more than one member of Lydian Staff Involved?*
Staff Members Name:*
First Name Last Name
Date of Incident:*

Day
Month
Year
Time Of Incident:*

: Hours

Minutes
Where and When did the incident occur?*
Primary Location e.g. service users home (including Address & Postcode if appropriate)
Exact location:*
Actual location of incident e.g. kitchen, bedroom etc.
Outline apparent circumstances of the incident (give brief factual objective details)*
Outline what happened together with any relevant circumstances. Where applicable, what was the person doing? Were there any contributory factors?
Outline the complaint as received*
Outline the complaint as received.
Was the incident caused as a result of behaviours of concern related to a specific illness or diagnosis?*
If yes, is this documented in their Care Plan?*
Did the person/individual suffer an injury as a result of the incident?*
Which part of the body was affected? e.g. back, left shoulder, right eye, neck, trunk etc.*
Identify all areas affected
What nature of injury was sustained? e.g. abrasion, bruising, laceration, sprain/strain, fracture etc.*
If more than one body part is identified above, please identify which injury relates to which body part
What was the apparent cause of injury? e.g. slip, trip, fall, physical assault etc.*
Type of incident
Was any equipment involved?*
Only choose ‘Yes’ if the equipment involved was linked to the cause of the incident.
Detail Equipment involved:*
For example Hoist.
Where relevant, have you reported to NIAC (NI Adverse Incident Centre)*
Was any property involved? (Home or personal possessions)?*
Only choose ‘Yes’ if the property involved was linked to the cause of the incident.
Detail Property involved:*
For example House Key.
Did the incident involve Medication?*
Please record the name(s) and dose/quantity of each medication involved. If the medication incident occurred due to a Pharmacy related incident, please also give details of the relevant Pharmacy:
Outline any remedial or other action taken following the incident (give brief factual details)*
What action was taken at the time the incident was discovered.
Persons notified including designation / relationship to Service User*
Name, designation and contact details of any witnesses*
Witnesses are only those individuals who saw the incident occurring – not who came across the incident after the event.

Call us: 028 43 725 385

Incident Record Form

Lydian Care

Incident Record Form

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Incident Record Form

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