Physician Office Incident Report

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Are you looking for a professional Physician Office Incident Report? If you've been feeling stuck or lack motivation, download this template now!

Do you have an idea of what you want to draft, but you cannot find the exact words yet to write it down or lack the inspiration how to make it? If you've been feeling stuck, this Physician Office Incident Report template can help you find inspiration and motivation. This Physician Office Incident Report covers the most important topics that you are looking for and will help you to structure and communicate in a professional manner with those involved. 

  Age Gender Medicaid Medicare Date of Office Visit Purpose of Office Visit ICD-9 Code for description of incident Level of Surgery (II) or (III) INCIDENT INFORMATION Incident Date and Time Location of Incident:  Operating Room  Recovery Room  Other Note: If the incident involved a death, was the medical examiner notified  Yes Was an autopsy performed  Yes  No  No A) Describe circumstances of the incident (narrative) (use additional sheets as necessary for complete response) DH-MQA1030-12/06 Page 1 of 3 B) ICD-9-CM Codes Surgical, diagnostic, or treatment procedure being performed at time of incident (ICD-9 Codes 01-99.9)

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