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Effective Date: 
2/2020

Documents

 

Instructions

Effective Date: 2/2020

 

Purpose

Form 6101 is used to notify Texas Health and Human Services Commission (HHSC) of an incident and the actions taken by the facility.

 

Procedure

Submit each form separately within five days of the incident. Do not submit multiple incidents in one document.
Explain how the facility will improve care as a result of the incident. Complete the entire form with all requested attachments so that HHSC may review the incident without requiring additional information or documents.

 

Transmittal

Submit each completed form by one of the following (email, fax or mail):

Email: cii.hcq@hhsc.state.tx.us
Fax: 1-833-709-5735 or 512-206-3985
Mail: Texas Health and Human Services Commission
Complaint and Incident Intake
P.O. Box 149030, Mail Code E-249
Austin, TX 78714-9030

 

Detailed Instructions

Print or type the information and provide as much information as possible. Use the facility name and license number as listed on your license.
Reportable IncidentCheck the appropriate box:

  • Death of a patient, newborn or fetus during the course of labor in the center.
  • Death of a patient or newborn occurring within 24 hours of discharge or transfer to another facility.

Date of Report Enter the report date.

Date of Incident Enter the date of the incident.

Time of Incident Enter the time of the incident and check A.M. or P.M.

Facility License No.Enter the facility license number.

Facility NameEnter the name of the facility.

Facility AddressEnter the street address, city, state, ZIP code.

Facility TelephoneEnter the area code and telephone number.

Reporter Name and TitleEnter the contact person and title the surveyor will ask for should a follow-up telephone call be needed.

Primary Phone No. and Secondary Phone No. Enter the area code and telephone numbers.

EmailEnter the email address.

Patient NameIf the incident involves a patient, enter the first, middle and last name.

Date of BirthEnter the patient’s date of birth.

GestationEnter the weeks and days for gestation.

Gravida and ParityEnter the gravida and parity.

Date Admitted to Current FacilityEnter the date the patient was admitted.

Date of DischargeEnter the date of discharge.

Diagnoses (all)Enter the diagnoses.

Baby Name – Enter the baby’s first, middle and last name.

Baby Date of Birth/Event – Enter the date of birth or date of event.

Baby Sex – Check the box for male or female.

Time of Death – Enter the hour and minute of death.

Date of Discharge – Enter the date of discharge.

Diagnoses (all)Enter the diagnoses.

2nd Baby Name – If a second baby, enter the first, middle and last name.

2nd Baby Date of Birth/Event – If a second baby, enter the date of birth or date of event.

Baby Sex – If a second baby, check the box for male or female.

Time of Death – If a second baby, enter the hour and minute of death.

Date of Discharge – If a second baby, enter the date of discharge.

Diagnoses (all)If a second baby, enter the diagnoses. 

Summary

When did you first learn of the incident? Enter the date and time.

On what shift did the incident occur? Check the box for day, evening or night.

Provide a brief summaryEnter what happened, who was involved (e.g., RN, LVN, PCT, MD, other), and the action taken at the time of the incident.

Did the patient receive any treatment? Check Yes or No and if yes, provide an explanation of the treatment provided to the mother and/or fetus/infant. Attach pertinent treatment documentation, if necessary. 

Provide a narrative report of your investigation Explain how you handled the incident and what actions you will take to reduce the potential for similar incidents in the future.

Action you will take as a result of this incidentCheck all boxes that apply.

Patient Transfer – Complete only if the patient was transferred to another facility:

Facility Name Enter the name of the facility.

Date of Transfer Enter the date of transfer.

Facility AddressEnter the street address, city, state, ZIP code.

Facility TelephoneEnter the area code and telephone number.

Signature, Printed Name and Date The supervising authority signs, prints his/her name and enters the date. Then, email, fax or mail the completed incident form to the number or address provided above under Transmittal.