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 document that helps facilities report and track incidents related to patient care. This form is used in situations where an unexpected event occurs at the facility, such as a fire, patient death, or involuntary transfer of a patient.

The form requires specific information about the incident, including the date, time, and details of what happened. It also asks for patient information if the incident involves a patient, including their name, date of birth, and date started on dialysis. The report must be submitted within one business day if the incident resulted in an injury or within 10 working days for other incidents.

Key features of this form include the requirement to report incidents that result in patient harm, death, or involuntary transfer. Facilities are responsible for submitting reports promptly and accurately. By using this form, facilities can ensure compliance with regulations and maintain a high level of patient care.

• This form is used by End Stage Renal Disease (ESRD) facilities to report incidents related to patient care.
• Incidents that must be reported include fires, patient deaths, involuntary transfers, and hospitalizations.
• The form requires specific information about the incident, including date, time, and details of what happened.