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Ct dph reportable events 2026
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- Click ‘Get Form’ to open the ct dph reportable events form in the editor.
- Begin by entering the Facility Name and Address, along with the Telephone number. Ensure that all details are accurate for proper identification.
- Fill in the Bed Capacity, CCNH, and RHNS fields as applicable. Select the Classification (A, B, C, D, E) based on your event type.
- Indicate if this is a follow-up report by selecting 'Yes' or 'No'. If 'Yes', attach the original report as instructed.
- Provide Patient Information including Name, Age, Date of Admission, Room Number, Current Diagnoses, Time and Date of Event. Specify AM or PM for clarity.
- Detail the Location and Nature of the Event. Include any Injury, Distress or Discomfort experienced by the patient.
- Document Functional Status before and after the event along with Mental and Physical Status assessments.
- Record details of Physician Notification including Name and Date/Time of Notification. Indicate if a Physical Exam was conducted.
- Complete sections on Family Notification, Police Notification, Investigation Initiated status and provide a signature from both the person filing the report and Administrator.
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