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 healthcare providers document and report various types of incidents, including patient abuse, neglect, exploitation, or unprofessional conduct, as well as fires that cause injury to a person or result in the death of a patient.

The form is divided into two sections: Section 1, which captures information about the incident itself, such as the date and time of the incident, facility details, and reporter contact information; and Section 2, which provides patient-specific data if the incident involves a patient. The reportable incidents listed in Section 1 include fires that cause injury or death, patient stays exceeding 23 hours, 9-1-1 activations, and emergency transfers to hospitals.

This form should be used whenever an incident occurs at a freestanding emergency medical care facility that meets the criteria outlined in Section 1. By completing this report, healthcare providers can ensure compliance with regulatory requirements and provide valuable information for quality improvement initiatives and patient safety efforts.