This customizable document, Performance Improvement Department - Notification Form, is taken from MCN Healthcare’s Behavioral Health Partial Hospitalization Program Policy and Procedure Manual. For more than 20 years, MCN has been the health care industry’s leading provider of policy and procedure templates, forms, competencies and other compliance tools.

MCN provides more than 80 health care specific policy and procedure manuals for Acute Care Hospitals, Ambulatory Care, Behavioral Health, Home Health, Physician Practice, and Long Term Care. MCN’s policy and procedure manuals focus on the latest healthcare "hot topic" issues related to patient safety and prevention of medical healthcare errors.

Here is some sample content from Performance Improvement Department - Notification Form:

	PERFORMANCE IMPROVEMENT DEPARTMENT NOTIFICATION FORM Do Not Photocopy This Report is Confidential - Not a Part of the Medical Record Section I If not a patient, complete following two 2 items: Name of Patient or Person Involved Medical Record or Other Identification Number Print Your Name Witnesses: Location: Section II Sex: q M q F Age: Description of Occurrence - Briefly describe what happened: Name the equipment, drug, treatment or procedure, etc., involved and parts of the body affected. Do not mention names of individuals in this section: Date of Occurrence: Time of...
Second excerpt:
	...one, i.e., an error in medication. 2. Whoever discovers the incident makes out this form. 3. After filling out this form, give it to your supervisor by the end of the shift. The supervisor is responsible to forward this form to the Performance Improvement Director within 24 hours. 4. It is not desirable to mention names other than the person patient involved and the person making out the form. 5. Do not photocopy for your records. 6. This form is confidential and is stored in the...