Adverse Event/Incident Note (Reiki)

Adverse Event/Incident Note (Reiki Session)

Date/Time of Event: [Date and time of event]

Date/Time of Note: [Date and time of documentation]

Author: [Name, role, credentials]

Encounter Type: [inpatient / outpatient / clinic]

Location: [Location of session/event]

Persons Present: [Reiki practitioner, chaperone if present, other staff involved in response]

Event Summary

Event: [One-sentence objective description of what occurred] (Keep neutral and factual; avoid speculation or assigning blame.)

Category: [Physiologic reaction / Emotional-psychological distress / Boundary-consent issue / Safety-environmental issue / Other]

Severity: [No harm evident / Mild / Moderate / Severe / Unable to determine]

Disposition: [Resolved during visit / Session stopped and patient monitored then discharged / Escalated to RN-MD-APP / Rapid response-EMS activated / Transfer to higher level of care / Patient declined evaluation or left]

Pre-Event Context

• [Reason for Reiki session and relevant clinical context]
• [Consent status: verbal or written, with date/time if known]
• [Touch modality agreed upon: hands-on / hovering / mixed; areas excluded from touch]
• [Relevant precautions known at time of session] (e.g., fall risk, prior syncope, known triggers)
• [Baseline vitals prior to session] (If not obtained, state: "Vitals not obtained prior to session.")
• [Baseline affect and functional status if relevant to interpreting the event]

Event Narrative

(Provide a chronological, time-stamped account using objective language. Include verbatim quotes for key patient statements, requests to stop, distress descriptors, or boundary concerns. Do not speculate on intent or include internal incident report identifiers.)

• [Time]: [Practitioner activity immediately prior to onset]
• [Time]: [Patient-reported symptoms] (Use verbatim quotes when applicable.)
• [Time]: [Objective observations: appearance, behavior, vital sign changes, environmental concerns]
• [Time]: [Boundary/consent concern if applicable: verbatim statement and immediate response]
• [Time]: [Subsequent course and further observations]

Assessment and Response

Assessment:

• [Vital signs obtained with times: initial and repeat values] (If not obtained, state why.)
• [Focused exam findings relevant to the complaint with pertinent positives and negatives]
• [Mental status and affect if emotional distress occurred]
• [Clinical impression with uncertainty noted if applicable]

Immediate Actions:

• [Session stopped at time]
• [Positioning and safety measures taken]
• [Grounding or supportive interventions provided]
• [Staff escalation: who contacted, time, and response]
• [Treatments provided: medication/oxygen/fluids with route, dose, time, and response] (If none, state: "No treatments provided.")

Patient Response:

• [Clinical course over time: improvement or worsening]
• [Repeat vitals with times] (If not repeated, state why.)
• [Functional status prior to disposition]

Plan and Notifications

Notifications:

• [Who was notified (name, role), when, and relevant content of communication]
• [What patient was told about the event, their condition, and next steps]

Patient Instructions:

• [Return precautions and red flags tailored to symptoms]
• [Follow-up recommendations with timeframe: PCP / urgent care / ED / behavioral health as appropriate]
• [Patient understanding or refusal documented]

Follow-Up Plan:

• [Planned follow-up contact: timing and responsible staff]
• [Modifications for future Reiki sessions if patient wishes to continue]
• [Statement that appropriate internal notifications were completed per policy] (Do not include report numbers or privileged content.)

Condition at Discharge/Transfer: [Stable / Improved / Unchanged / Worsened] — [Ambulatory status, escort, or transfer details]

(If information was not obtained or is unknown, state explicitly rather than omitting. Keep narrative factual and objective. Do not include internal incident report numbers or quality review content in this clinical note.)