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:*IncidentMedication ErrorPersonal accident or any accidentComplaintNotifiable EventNear MissMissed or Late Domiciliary CallsSelect from drop down list the type of report you are making.Homecare or Healthcare:HomecareHealthcareDate 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:*Carol SavageRachel DeeryHealthcare Site or Hospital:The name of the hospital or private site where the incident/accident or complaint occurred within.Was a Service User Involved?YesNoService 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?*YesNoStaff Members Name:* First Name Last Name Was more than one member of Lydian Staff Involved?*YesNoStaff 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?*YesNoUnknownIf yes, is this documented in their Care Plan?*YesNoUnknownDid the person/individual suffer an injury as a result of the incident?*YesNoWhich part of the body was affected? e.g. back, left shoulder, right eye, neck, trunk etc.*Identify all areas affectedWhat 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 partWhat was the apparent cause of injury? e.g. slip, trip, fall, physical assault etc.*Type of incidentWas any equipment involved?*Only choose ‘Yes’ if the equipment involved was linked to the cause of the incident.YesNoDetail Equipment involved:*For example Hoist.Where relevant, have you reported to NIAC (NI Adverse Incident Centre)*YesNoWas any property involved? (Home or personal possessions)?*Only choose ‘Yes’ if the property involved was linked to the cause of the incident.YesNoDetail Property involved:*For example House Key.Did the incident involve Medication?*YesNoPlease 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.
