TX HHS Form 6103. End Stage Renal Disease Facility Incident Report

The TX HHS Form 6103, "End Stage Renal Disease Facility Incident Report", is a crucial tool for reporting incidents that occur in end stage renal disease facilities. This form helps facility staff and administrators document and report significant events, such as patient injuries or deaths, hospital transfers, and hepatitis B conversions, within a timely manner.

The form requires important information to be reported, including the date of incident, time of incident, facility name, and patient details if applicable. Key sections include "Reportable Incident" and "Patient Information", which must be completed for incidents involving patients. The form also specifies reporting deadlines, with reportable incidents requiring submission within one business day.

This form is essential for end stage renal disease facilities to maintain compliance with regulations and ensure patient safety. It should be used whenever an incident occurs that meets the reportable criteria outlined in the form. By completing this form accurately and promptly, facility staff can help identify trends, implement corrective actions, and improve overall care for patients with end stage renal disease.