Adverse Event/Incident Report (Massage Therapy)

Report Date/Time: [Date and time of report completion]

Event Date/Time: [Date and time event occurred, 24-hour format]

Location: [Facility name and specific location]

Report Type: [Incident – reached client / Near Miss – did not reach client / Unsafe Condition – no client exposure]

(Use neutral, fact-based language throughout. Document only what was observed, measured, or reliably reported. Use time-stamped sequencing. Avoid conclusions about fault or definitive causality. Use direct quotes for key client statements. Keep observed facts separate from clinical impressions.)

Client and Encounter Information

(Include only when a client is involved; omit this section entirely for unsafe-condition-only reports.)

• Client Name: [Client full name]
• Date of Birth: [DOB]
• Contact Number: [Phone number]
• Appointment Date/Time: [Date and start time of appointment]
• Service Type and Modality: [Service type and modality]
• Body Regions Treated: [Regions addressed]
• Positioning: [supine / prone / side-lying / seated / varied]
• Products Used: [Oils, lotions, topicals with names/brands if known]
• Adjuncts/Devices: [hot stones / heat packs / cold packs / cupping / gua sha / percussive device / aromatherapy / other / none]
• Relevant Pre-Session Factors: [Pre-session factors directly relevant to the event] (Include only factors directly pertinent to the event, such as reported dehydration, fasting, recent illness.)
• Allergies/Sensitivities Status: [Allergies listed / Known sensitivities listed / Not assessed / Not on file]
• Identified Contraindications: [Contraindications identified and how addressed] (If none identified, state "None identified.")

Event Summary

[One-sentence summary including timing, primary symptom or event type, immediate actions, and disposition]

Event Classification

Category: [Physiologic / Dermatologic / Musculoskeletal flare / Emotional or psychological distress / Fall or near fall / Thermal injury / Equipment or environmental issue / Boundary or safety event]

Harm Level: [No harm – resolved without injury / Mild – transient, minimal intervention / Moderate – medical evaluation recommended or obtained / Severe – EMS activation or significant injury]

Timeline of Events

(List in chronological order with time stamps; use "approx" if estimated.)

• [HH:MM] – [Pre-event context and client state]
• [HH:MM] – [Symptom or event onset and client statement] (Use direct quotes for key client statements.)
• [HH:MM] – [Immediate action taken]
• [HH:MM] – [Assessment checkpoint]
• [HH:MM] – [Escalation or notification made] (If applicable.)
• [HH:MM] – [Disposition or handoff]
• (Add additional time-stamped entries as needed.)

Assessment

Client-Reported (Subjective)

• [Onset timing and circumstances]
• [Symptom quality and severity] (Use 0–10 scale if applicable.)
• [Location and radiation of symptoms]
• [Associated symptoms]
• [Prior history of similar reactions] (If reported.)

(Include relevant direct quotes.)

Observations (Objective)

• [General appearance and distress level]
• [Mental status]
• [Skin findings] (If relevant; include distribution and character.)
• [Visible injuries] (If present; include location and description.)
• [Vital signs: HR, BP, method/position] (If obtained. If vitals not taken, document reason.)

Impression

[Working impression as hypothesis] (Do not assign definitive causality. Clearly distinguish observed facts from client report and clinician hypothesis.)

Actions Taken

• [Immediate interventions: treatment stopped, position change, product removal, hydration, compress, first aid]
• [Escalations with times] (If applicable: supervisor notified, EMS called, emergency protocols activated.)
• [Client education provided and whether written instructions given]

Client Disposition

Disposition: [Session ended early / Observed then discharged / Discharged to escort or caregiver / Referred to urgent care or PCP / EMS transport / Left against advice]

Condition at Departure: [Symptoms resolved / improving / persistent]; [Mobility status]

If Client Declined Recommended Evaluation: [Recommendation made; client's stated reasoning; capacity concerns if any; direct quote of refusal] (Only include if refusal occurred.)

Notifications

• Internal: [Names, roles, and times notified]
• External: [Emergency contact, client's healthcare provider if authorized, product manufacturer if relevant] (Include lot/batch number for product issues.)

Client Communication

[Summary of what was communicated to client about the event] (Include what is known and unknown, acknowledgment of concerns, next steps, how to reach clinic, and questions asked with answers provided.)

Follow-Up Plan

Planned Follow-Up

Timing: [Same day / Next day / Within 72 hours / Other]   Responsible Person: [Name or role]   Purpose: [What will be assessed]

Follow-Up Contact Log

• [Date/Time] – [Method] – [Client status]; [New care received]; [Guidance provided]; [Next steps]
• (Add follow-up entries as addenda; do not overwrite original report.)

Contributing Factors (Optional)

(Quality improvement analysis – separate from factual event narrative; may be completed by reviewer.)

• Potential Contributing Factors: [Client factors / Technique factors / Product factors / Environment or equipment factors / Process gaps]
• Immediate Mitigations Completed: [Actions taken]
• Proposed Prevention Steps: [Process changes, training, equipment or product modifications]

Reporter: [Name], [Credentials or role]

Report Completed: [Date and time]