Templates · Free template · Safety and incidents
Adverse Event Report Template
A printable adverse event report for the day something does not go to plan: a clear factual account of what happened, what you did, how it resolved, and who was informed.
Write it factually and write it promptly
An incident report is a factual record, not a conclusion. Record what was observed, when, what was done, and what the patient reported, in that order, at or close to the time. Avoid speculating about cause or assigning blame; that belongs in a later review.
Note follow-up and outcome, and who was informed, whether that is the patient's physician, your insurer, or your college where notification is required. Requirements vary, so check with your insurer and regulator.
Adverse Event Report
Patient and treatment
Event
Response
- Emergency services called
- Reversal agent or medication given
- Patient monitored until stable
- Referred to physician / hospital
Follow-up
- Patient informed of findings and next steps
- Insurer notified
- College / regulator notified where required
- Product or device reported to manufacturer
Sign-off
Template from zdrovia.ca/templates/adverse-event-report-template/ · Adapt to your college's documentation standard before use.
Chart it once, find it every visit after
Zdrovia comes with starter chart templates for aesthetics, including a neurotoxin treatment record and a laser session record, and you can adapt any of them to match this one. Fill the chart on a tablet during the treatment, or let the AI Scribe complete it from what you say out loud. Products and lots dispensed from inventory land on the same patient record, and photos attach to the visit. Free for solo practitioners, with data stored in Canada.
See how Zdrovia is set up for med spas.
Frequently asked questions
Who needs to be notified after an adverse event?
That depends on the event, your regulator, and your insurer. Ask your insurer and college in advance so you know before you need to.
Should I write down my opinion on the cause?
Stick to facts. Causes are established later, when there is more information.
Related
This template is a documentation aid, not clinical guidance. It records decisions about dosing, depth, and settings; it doesn't make them. Documentation standards vary by province and profession, so adapt it to your regulatory college's requirements.