Patient Name:

1. TML/MSH Microbiology Incident Report TO BE COMPLETED BY INDIVIDUAL REPORTING THE INCIDENT. It should be completed when any unexpected, unusual, or unplanned occurrence affecting patient's specimen, blood product, or report, or when a customer complaint is received. Please provide Format? How long are this fields? Patient Name: Medical Record Number: HIS Specimen #: Patient Status (select one): Inpatient Outpatient Pulldown Menu Soft (LIS) #: Date & Time of Incident Occurrence: hh:mm AM PM yy/mm/dd Is this an Employee? Pull-down of all Depts in MSH or only some ID Depts? TECHNICAL INFORMATION Date & Time of Incident Detection: hh:mm AM PM yy/mm/dd Name of Complainant: Department: (xxx) xxx-xxxx (xxx) xxx-xxxx Telephone No: Pager No: Pull-down of MSH And TML or others– ID? Origin of Incident (Select a Department): Site (Hospital) of Detection: 1 2 3 4 5 6 LOG REPORT Answer questions on second page please Action Taken (please provide a detailed description in your own words): TECHNICAL INFORMATION

2. 1. Pauline, we need to ID size of each answer field (ie: max no of characters allowed in ea)? 2. We need to ID whether we allow 1 checkmark in one box only or multiple? 3. This will be a scroll down menu. 4. Do you want the user to type the start of the name and when the system recognizes the first few letters from the Employee Table it will select a name and the user just has to confirm name by pressing enter? 5. Will Details be free flow text? If so, you can’t automate a report on free-flow text remember that. 6. I suggest a multiple choice (please provide choices) to allow for reporting later, we can add a free flow text column below for comments? Unless you want this all to be free flow text? Please provide the following info for Log Report Section.