CHANGES IN INDIVIDUAL CONDITION AND UNUSUAL EVENTS FORM
Use this form to document significant changes in physical condition or mental status and unusual events. This form does not replace an Incident Report when an event is reportable.
1. Individual and Event Information
Individual Name:
*
First Name
Last Name
Date of Event:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Event:
*
Time Event Began:
*
Hour Minutes
AM
PM
AM/PM Option
Program / Service:
*
Duration (if applicable):
*
Person Completing Form:
*
First Name
Last Name
Date Form Completed:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
2. Type of Change or Unusual Event
Type of Change or Unusual Event Options
Vomiting
Choking
Fall
Disorientation / confusion
Significant or unusual pattern of behavior
Seizure
Significant change in physical condition
Significant change in mental status
Other unusual event or change
If other, describe:
3. Objective Description of Change or Event
Describe what was observed and the relevant circumstances. Record facts only. Do not speculate about cause unless the cause is known and can be documented objectively.
4. Action Taken and Response
Immediate action taken to protect health/safety:
Intervention / first aid provided:
Individual's response / condition following action:
5. Medical, Emergency, and Notifications
Emergency medical services contacted?
Yes
No
Emergency medical services contacted - Time:
Hour Minutes
AM
PM
AM/PM Option
Medical attention obtained?
Yes
No
Medical attention obtained - Where / Provider:
Supervisor / on-call notified?
Yes
No
Supervisor / on-call notified - Time:
Hour Minutes
AM
PM
AM/PM Option
Guardian notified?
Yes
No
N/A
Guardian notified - Time:
Hour Minutes
AM
PM
AM/PM Option
Family / other appropriate person notified?
Yes
No
N/A
Family / other appropriate person notified - Time:
Hour Minutes
AM
PM
AM/PM Option
Case manager / other provider notified?
Yes
No
N/A
Case manager / other provider notified - Time:
Hour Minutes
AM
PM
AM/PM Option
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Additional notification details / instructions received:
SECTIONS BELOW TO BE COMPLETED BY ADMINISTRATIVE PERSONNEL
6. Reportable Incident Determination
Does this event meet the definition of a reportable incident under applicable requirements, including 460 IAC 6-9-5?
Yes
No
Unsure / Refer for determination
If yes or unsure, was the applicable Incident Reporting process initiated?
Yes
No
N/A
Incident Report date/time (if applicable):
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Incident/report reference #:
Important: Do not delay an Incident Report while waiting to complete routine progress notes or this form.
7. Other Provider Information (Complete when applicable)
Other provider / agency:
Name of person reporting:
First Name
Last Name
Method of communication:
Email
Phone
Written
Other
Was information incorporated into individual's record?
Yes
No
N/A
Other provider information must be provided to The Arc within 24 hours of the event or by noon of the next business day, whichever is later, unless the event is also a reportable incident. Reportable incidents require information within 24 hours.
8. Supervisory / Designated Administrative Review
Review completed by:
First Name
Last Name
Review Actions Checklist
Additional action necessary
Guardian / family notification needed
Service plan requires review
Incident Report required
Pattern of events warrants further assessment/intervention
Physician / nurse notification needed
Case manager / other appropriate person notification needed
Risk-management strategies require review
Additional documentation or investigation necessary
No additional action indicated
9. Review Findings / Follow-Up Actions
Review Findings / Follow-Up Actions
Related/repeated events identified?
Yes
No
Unknown
If yes, describe action taken:
10. Documentation and Authentication
Observed by:
*
First Name
Last Name
Signature / electronic authentication:
*
Date/time documented:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date/time authenticated:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reviewed by:
First Name
Last Name
Reviewer signature / electronic authentication:
Date information received:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time received:
Hour Minutes
AM
PM
AM/PM Option
Received by Arc personnel:
First Name
Last Name
By whom:
First Name
Last Name
Date/time:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Record location / filing confirmation:
Date filed:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Changes in Individual Status and Unusual Events Form | The Arc of the Wabash Valley
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