Escalation and Incident Report

Escalation & Incident Report

Who is filling out this form? *

Date of Incident: *

Time of Incident: *

Is this a patient or a employee? *

Patient First Name *

Patient Last Name *

Patient Phone *

Patients Date of birth

Have you contacted 911 for immediate intervention? *

These symptoms require immediate emergency intervention CALL 911

Severe allergic reaction (anaphylaxis): Difficulty breathing, swelling, rash, or throat tightness.

Chest pain or signs of a heart attack: Pain radiating to jaw/arm, nausea, sweating.

Severe shortness of breath or difficulty breathing.

Loss of consciousness or unresponsiveness.

Seizures or new onset neurological symptoms.

Suspected stroke: Slurred speech, facial droop, weakness on one side of the body.

Routine Escalation to APRN (Next Scheduled Visit or Within 72 Hours)

Mild allergic reaction: Mild itching or redness.

Constipation related to weight loss treatments < 7 days (Semaglutide, Tirzepatide, etc.).

Patient requests change in prescription or dosage (weight loss, hormone therapy, etc.).

Mild sore throat post-treatment.

Mild flu-like symptoms after an injection (e.g., post-IV therapy or PRP treatment).

Delayed onset muscle pain after IV therapy or injections.

Minor skin irritation from peels, microneedling, or laser treatments.

Minor dissatisfaction with cosmetic results (to be addressed at follow-up).

Emergency Contact Information

APRN On-Call: Kara or Liv (FORM WILL BE SENT IMMEDIATELY)
Medical Director Contact: Dr Marek 859-583-7781
Local Emergency Services: 911
Poison Control: 1-800-222-1222

This policy is in place to protect patient safety and support RNs in decision-making. RNs should err on the side of caution and escalate concerns whenever uncertain. If in doubt, escalate.

Describe the incident *

Immediate Actions Taken: *

Witnesses: *

Follow up actions taken, if none please update on client notes in blvd *

Upload Images if needed

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