TX HHS Form 6105. Hospital Facility Incident Report

The TX HHS Form 6105, Hospital Facility Incident Report, is a crucial tool for reporting incidents related to the operation of hospitals or facilities. This form helps healthcare providers and administrators document and report various types of incidents, including abuse, neglect, exploitation, and emergency medical treatment violations.

This reportable incident form requires key information such as date of report, date of incident, time of incident, facility license number, facility provider number, and facility name. The form also includes sections for patient information, if the incident involves a patient, including patient name, date of birth, time of admission, discharge, and death (if applicable). Additionally, the suspected cause of death and diagnoses must be reported.

The TX HHS Form 6105 should be used as soon as possible to report incidents related to the operation of facilities or services. This form is essential for ensuring compliance with regulations and maintaining a safe environment for patients and staff. By completing this form, healthcare providers can help prevent future incidents and ensure that necessary actions are taken to protect vulnerable populations.