Physician Office Incident Report
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Business Entreprise report rapport office Bureau patient Incident Procedure Procédure Incident Report Sample Exemple de rapport d'incident Incident Report Samples Exemples de rapports d'incident Surgical Chirurgical
Are you looking for a professional Physician Office Incident Report? If you've been feeling stuck or lack motivation, download this template now!
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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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