ER, Hospitalization and Urgent Care Entry Form

***FORM UPDATE FY 25***

Some fields have been removed to shorten the form and streamline data collection.

If there are any questions, please let your IT dept. know. 

Thanks.  

 

Please enter your full name.

Add a fourth email for someone who needs a copy of the form responses or leave blank.

K. Type of Report
N. Person Recommending the Visit
O. Was 911 used?
Q. When was the guardian notified?
R. Is there an Unusual Incident Report associated with this visit?
Z. Disposition from ER/Hospital
Please provide the following information in question "ZE":

1. What led up to the event described above?

2. What was the exact issue that caused the event?

3. What was staff's immediate response to the event?

4a. What testing was done?

4b. What was the results of the testing?

5. What treatment was ordered as a result of the testing?

6. Is there any follow-up needed related to this event?

Please give a brief, specific description that includes all requested information (see instruction above).