Major Injury Determination Form free printable template

MAJOR INJURY DETERMINATION FORM This form must be completed IF the facility is relying on the physician designee or extender to determine whether a major injury has occurred. NOTE The facility may independently determine that a major injury has occurred and submit a self report. Extender of the above named patient state that I have read the foregoing Determination Form know the content thereof and have made the determination of whether the patient s injury should be designated as a major injury...based on the disclosure of the above information available on this date. The facility shall submit this Form to the Physician Designee or Extender within 24 hours of when the injury occurred* A signed copy of this Form must be obtained by the facility from the physician designee or extender within 72 hours of the injury. If the physician designee or extender refuses to complete the Form or is unavailable for completion and signature the DIA Director or designee must be notified of the injury...within one business day. facility in the resident s clinical record and the facility shall notify the department of the major injury maintained by the facility with the resident s clinical record. TO BE COMPLETED BY THE FACILITY Resident name Date and time of the injury Description of injury Circumstances of the incident causing the injury Resident s previous functional ability Signature of Facility Representative Completing Form Print Name...-----------------------------------------------------------------------------------------------------------------------------------------------------------------TO BE COMPLETED BY THE PHYSICIAN DESIGNEE OR EXTENDER Patient s prognosis CHECK ONE After reviewing the circumstances injury and prognosis of the patient I believe the injury sustained is a major injury pursuant to 481 Iowa Administrative Code 50. 7 1 a 3. and to the best of my knowledge barring any complications I believe the patient...will return to his/her previous functional status. Date Time Signature of Physician Designee of Physician or Physician Extender Designee means another physician or physician extender in lieu of the attending physician*. The facility shall submit this Form to the Physician Designee or Extender within 24 hours of when the injury occurred* A signed copy of this Form must be obtained by the facility from the physician designee or extender within 72 hours of the injury. If the physician designee or...extender refuses to complete the Form or is unavailable for completion and signature the DIA Director or designee must be notified of the injury within one business day. If the physician designee or extender refuses to complete the Form or is unavailable for completion and signature the DIA Director or designee must be notified of the injury within one business day. facility in the resident s clinical record and the facility shall notify the department of the major injury maintained by the...facility with the resident s clinical record. facility in the resident s clinical record and the facility shall notify the department of the major injury maintained by the facility with the resident s clinical record. TO BE COMPLETED BY THE FACILITY Resident name Date and time of the injury Description of injury Circumstances of the incident causing the injury Resident s previous functional ability Signature of Facility Representative Completing Form Print Name...-----------------------------------------------------------------------------------------------------------------------------------------------------------------TO BE COMPLETED BY THE PHYSICIAN DESIGNEE OR EXTENDER Patient s prognosis CHECK ONE After reviewing the circumstances injury and prognosis of the patient I believe the injury sustained is a major injury pursuant to 481 Iowa Administrative Code 50.