QAPI Program Utilization_Manual

ON-CALL REPORT COMPLAINT REPORT Date: ____________________ Time: _________________ Employee: ___________________________________________________________ Report related Patient: __________________________ MR:_______________ Incident: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Action taken: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ MD notifi ed: ____ Yes ____ No Comment:____________________________ Follow up Date: ________________ Satisfied solution: Yes No Comments: ____________________________________________________________ ______________________________________________________________________ Plan to prevent repeat problem: ____________________________________________ ______________________________________________________________________ ____________________________________ ____________________ Signature /Title Date 56