Adverse Event/Incident Note (Yoga Therapy)

Date/Time of Incident: [Date and time]

Date/Time of Documentation: [Date and time]

Location: [Setting and specific area]

Yoga Therapist: [Name and credentials]

Patient: [Patient identifier per policy]

Late Entry: [Current date/time and information source] (Only include if documenting after the fact; state how information was obtained.)

Event Summary

Event Type: [Fall/Near-fall / Pain flare/musculoskeletal strain / Dizziness/near-syncope / Shortness of breath/chest symptoms / Neurologic symptoms / Emotional distress/trauma response / Skin/joint injury / Equipment/environmental hazard / Other]; Severity: [Near miss - no harm / Incident - no harm / Incident - mild harm / Incident - moderate/severe harm]

[Factual narrative of event] (3–6 sentences: when and where event occurred; practice/pose being performed; what was observed and patient-reported symptoms using direct quotes for key statements; whether witnessed; immediate outcome. Use neutral verbs such as stated, reported, observed, assisted. Include props, assist level, or environmental factors only if directly relevant. If event was unwitnessed or information is incomplete, state this explicitly.)

Assessment

Immediate Findings: [Safety check and relevant findings] (Include level of consciousness, visible distress or injury, and event-specific findings. For falls: position found, ability to bear weight. For pain: location, severity, ROM. For dizziness: positional symptoms, resolution with rest. For emotional distress: observed behavior and any safety concerns.)

Vitals/Measures: [Obtained measures with times] (Include vital signs, pain scores, or other objective measures with timestamps. If required measures were not obtained, briefly state why. Omit this field entirely if no objective measures were taken.)

Actions & Response

• Immediate Actions: [Actions taken] (Stopped practice, assisted to safe position, first aid within scope, monitoring duration.)
• Escalation: [Who contacted, when, and guidance received] (Include times and roles—RN, provider, EMS—and instructions given.)
• Patient Response: [Response to interventions] ([improved / unchanged / worsened]; tolerance of modified activity; time course if relevant.)
• Refusals: [Declined interventions and alternatives offered] (Only include if patient refused escalation or recommended care; document stated reason if provided.)

Plan

Modifications: [Changes to yoga therapy plan] (Poses/techniques discontinued, safer alternatives, new assist level or environmental controls, updated precautions. If no changes warranted, briefly justify.)

Patient Instructions: [Instructions provided] (Activity modifications; red-flag symptoms for urgent care tailored to event type; follow-up recommendations including PCP/specialist contact and any medical clearance required before next session.)

Handoff/Communication: [Handoff recipient and key safety points communicated] (If disclosure conversation occurred with patient or family, document factual content and follow-up plan only—no speculation about causality.)

(This clinical note documents only clinical facts, assessment, interventions, and plan. Do not reference internal incident reports, risk management notifications, quality reviews, opinions about preventability, or policy issues. Complete administrative safety reporting through the organization's designated system, separate from this clinical record.)