HODGES UNIVERSITY DEPARTMENT OF DENTAL HYGIENE MEDICAL EMERGENCY INCIDENT REPORT
This form must be completed following a medical incident. When an incident occurs, the Program Director must be notified and involved student clinician(s) and faculty must complete this form as soon as possible.
Student Name: ______________________________ Date: ______________ Time of the Incident: _________________________ Description of the Incident:
Blood Pressure: Finding:
Time: Time: Time: Time:
Finding: Finding: Finding: Finding:
Time: Time: Time: Time:
Finding: Finding: Finding: Finding:
Time: Time: Time: Time:
Pulse:
Finding: Finding: Finding:
Respiration: O2 Delivery:
Medications Administered:
Time of Administration: ___________________
Onset: Cessation of Breathing: Cessation of Pulse: CPR Initiated: EMS Called:
EMS Arrived:
Patient Released: Patient Response to Treatment:
Patient Released to:
Client Driven Home by: Follow-up call (time and name): __________________________________________________ Signatures: Supervising Dentist: Supervising Clinic Instructor: Student: ________________________________
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Dental Hygiene Program
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