Critical Incident Report User Guide Form 470-4698 - Iowa Medicaid ...

Iowa Department of Human ServicesIMPA Incident Reporting FormIMPA Users Guide – Revised May, 2010Fields in the Incident Information section of the Initial Report include information on the services which were beingprovided at the time the incident occurred.SERVICES WERE NOT BEING PROVIDED: - Select this checkbox if services were not being provided at the timethe incident occurred.SERVICES WERE BEING PROVIDED AT THE TIME OF THE INCIDENT: - Select this checkbox if services were beingprovided at the time the incident occurred. Indicate the procedure code in the W CODE narrative box andprovide the SERVICE NAME of the service being provided in the narrative box.Figure 8: Narrative of Incident, Part 1 Initial ReportFields in the Incident Information section of the Initial Report require a written narrative of the incident being reported.Describe what happened before the incident including environmental conditions and any cues given. Describe theincident in observable and measureable terms. Describe what occurred after the incident and how long the incidentlasted.Figure 9: Immediate Resolution, Part 1 Initial ReportFields in the Incident Information section of the Initial Report require information on the immediate resolution of theincident, specifically the assurance of health and safety for all persons involved. There are ten resolution factors listed.Select all that apply.DATE OF IMMEDIATE RESOLUTION: - Enter the date that the health and safety of all persons involved wasassured.RESOLVED BY PROVIDER STAFF: - Staff actions to immediately protect person(s) from harm, to assure that theenvironment was safe, to provide first aid or seek emergency medical attention and to notify a supervisor.INCARCERATION: - Confined in lawful detention by law enforcement officers.OUT-PATIENT MENTAL HEALTH: - The treatment, assessment, or counseling of the member for a cognitive,behavioral, emotional, mental or social dysfunction in other than an in-patient setting.Page 11