CMS-10525 Level Two Incident Intake Summary

LEVEL TWO INCIDENT INTAKE SUMMARY

INSTRUCTIONS: The organization must prepare a summary for the central office clinician to review prior to initiating a full investigation for Root Cause Analysis This worksheet is provided to aid the central office clinician in determining if this is a Level 2 event that requires a full Root Cause Analysis and Conference Call. PO’s should include all elements listed below and submit an email to [email protected] within 2 working days of the events occurrence.

Enrollment date:

Type of incident:

Location of incident:

Participant’s current status:

Significant diagnoses:

Summary of the care history:

Summary of the event:

Example April 28, 2014