Clinical Event Form

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UNIVERSITY OF PITTSBURGH SCHOOL OF NURSING
NURSE ANESTHESIA PROGRAM
Clinical Event Report
Program Notification MUST be within 24 hours of event. By phone or in person only.
Contact the Faculty on call (posted on student web)
Student Name:
Event:
(what best describes the problem)
Clinical Facility:
Coordinator Notified:
yes
Name:
Date Notified:
Student Notified Program:
Date:
Time:
Method: [Select one] Discussed With: [REQUIRED]
Instructions given to student:
Action required
Submit written report within 24 hours
Submit written report within 3 days
Additional instructions
Faculty Advisor: [Select Advisor]
Date of Clinical Event:
Time:
Operative Procedure:
Surgeon:
Assigned CRNA:
Assigned Anesthesiologist:
OR Number (if applicable):
Other Individuals Involved:
Internal Clinical Site Report Filed
yes
no
Factually describe the event and your involvement:
Follow-up by student:
Is any additional follow-up by student planned? If so, describe.
Management Plan submitted:
yes
N/A
Daily Evaluation submitted:
Student Signature
yes
Date
[must be signed after printing]
Revised: 8/22/2014
THIS FORM CANNOT BE ELECTRONICALLY SUBMITTED
N/A
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