TX HHS Form 6104. Freestanding Emergency Medical Care Facility Incident Report

The TX HHS Form 6104, Freestanding Emergency Medical Care Facility Incident Report, is a crucial tool for reporting incidents that occur in freestanding emergency medical care facilities. This form helps to ensure that any adverse events or near-misses are documented and addressed promptly, promoting a culture of safety and quality improvement.

The report requires information about the incident, including the date, time, and circumstances surrounding the event. It also asks for patient-specific data if the incident involves a patient, such as their name, date of birth, and chief complaint. The form covers various types of incidents, including abuse, neglect, exploitation, legal or unprofessional conduct, fire causing injury or death, and prolonged patient stays.

By completing this report, freestanding emergency medical care facilities can identify trends and patterns in adverse events, implement corrective actions to prevent similar incidents from occurring, and demonstrate their commitment to providing high-quality patient care. Key features of the form include required information about the incident, patient data if applicable, and follow-up actions or procedures that should be taken.

• The report is used to document and investigate incidents in freestanding emergency medical care facilities.
• The form requires information about the incident, including date, time, and circumstances.
• Patient-specific data is collected if the incident involves a patient.