Adverse Event/Safety Incident Note (Hypnosis)

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

Date/Time of Event: [Date and time of adverse event] (Include only if different from note creation.)

Author: [Name, credentials]

Care Setting: [outpatient clinic / inpatient unit / dental suite / procedure room / other: specify]

Mode: [in-person / telehealth - video / telehealth - phone] (If telehealth, note platform and any connection issues.)

Participants Present: [patient; guardian; interpreter; chaperone; support person; other staff: roles] (Omit interpreter and chaperone if not applicable.)

Patient Location: [Physical address or facility location / Location not confirmed] (For telehealth, document whether location was confirmed and whether patient was alone.)

Event Summary

[Concise 2–5 sentence summary of what occurred, including key signs/symptoms, when in the hypnosis process it occurred, immediate interventions taken, and outcome/disposition] (Front-load the safety outcome. Include phase: induction, deepening, suggestions, re-alerting, or post-session.)

Clinical Context

• Indication and Session Goal: [Reason for hypnosis and session goal]
• Hypnosis History: [New to hypnosis / ongoing care]; [approximate number of prior sessions]; [prior adverse reactions: yes/no and brief description]
• Relevant Conditions Increasing Risk: [trauma history / dissociative disorder / psychosis / seizure history / panic disorder / active substance use / other: specify] (Include only if relevant.)
• Medications/Substances Affecting Arousal or Attention: [List relevant prescriptions, PRNs, OTCs, substances] (If unknown and potentially relevant, document "not assessed.")
• Other Pertinent History: [Concise items relevant to current event only]

Pre-Session Safety and Intervention Details

• Consent: [Informed consent for hypnosis: obtained/not obtained; date]; [Telehealth consent: obtained/not applicable; date]
• Baseline Status Pre-Induction: [Distress level / rating scale if used]; [Orientation: person/place/time/situation]; [Vital signs if obtained]
• Telehealth Safety Readiness: [Backup phone number verified: yes/no]; [Emergency contact identified: yes/no]; [Patient not driving/operating machinery: confirmed]; [Privacy: adequate/inadequate; who else present] (For telehealth encounters only.)
• Hypnosis Intervention Parameters: [Start time – Stop time]; [Approximate duration]; [Technique type: eye fixation / progressive relaxation / conversational induction / imagery / other]; [Suggestion content categories] (Do not include verbatim scripts.)
• Phase When Event Occurred: [induction / deepening / suggestions / re-alerting / post-session]
• Environment: [Patient posture/position]; [Lighting]; [Privacy]; [Interruptions: specify if any]
• Facilitator: [Primary clinician]; [Trainee involvement: yes/no] (If technique details unavailable due to trainee-led segment, note that specifics are being obtained.)

Adverse Event Description

(Use a timestamped timeline. Include patient quotes for safety-critical statements. Distinguish subjective reports from objective findings.)

• [Time — onset]: [Subjective experience in quotes if applicable]; [Objective observations: behavior, speech quality, orientation, affect, psychomotor activity, physiologic signs]
• [Time — progression]: [Changes in symptoms/behavior; responsiveness to verbal cues; ability to follow commands]
• [Time — peak/severity]: [Severity indicators: attempts to flee, self-harm gestures, aggression, inability to re-orient, syncope-like features, emesis, other]
• [Time — resolution]: [Resolution course; partial/complete; residual symptoms]

• Dissociation Features: [depersonalization / derealization / time loss or amnesia / identity confusion / responsiveness to verbal cues] (Include only if dissociation present.)
• Event Classification: [incident / near miss / unsafe condition]; [harm level: none / mild / moderate / severe] (Include only if required by organizational policy.)

Immediate Interventions

(List in the order performed with timestamps when available.)

• Termination/Re-alerting: [Stopped hypnosis]; [Re-orientation steps used: counting up, eye opening, name/date/place orientation]
• Grounding/Stabilization: [Sensory orientation / paced breathing / muscle engagement / containment imagery / other]
• Supportive Communication: [Calm coaching, validation, limit-setting, safety-focused directives]
• Medical Actions: [Vitals obtained (values/time) / not obtained (reason and alternative assessment)]; [Glucose check]; [Oxygen/positioning]; [Medications administered with dose/route/time]; [Fluids/snack]; [Fall precautions] (Include only actions taken.)
• Safety Containment: [Continuous observation / removal of hazards / additional staff involved (roles) with rationale] (Include only if applicable.)
• Emergency Activation: [EMS activated (time/by whom) / Sent to ED (time/transport mode) / Consulted on-call service (name/time)] (Include only if applicable.)

Patient Response and Disposition

• Response to Interventions: [What improved; what persisted; patient-reported relief or ongoing symptoms]
• Status at Conclusion: [Orientation to person/place/time/situation]; [Ambulation safety]; [Tolerates oral intake]; [Understands plan and return precautions]
• Discharge: [Escort/support person present: name/relationship]; [Transportation plan]; [Explicit statement regarding driving]; [Return precautions provided] (Include only if discharged.)
• Transfer: [Destination]; [Handoff recipient: name/role]; [Time of departure] (Include only if transferred.)
• Clinical Reasoning for Disposition: [Why safe to discharge vs why escalation required]

Post-Event Safety Assessment

• Mental Status Exam: [Appearance]; [Behavior/psychomotor]; [Speech]; [Mood/Affect]; [Thought process]; [Thought content]; [Perception]; [Cognition/Orientation]; [Insight/Judgment]
• Suicide/Self-Harm Risk: [Ideation]; [Intent]; [Plan]; [Means access]; [Recent behaviors]; [Protective factors: supports, reasons for living, engagement in care]
• Dissociation Follow-up: [Grounding success]; [Residual depersonalization/derealization/amnesia]; [Ability to self-soothe] (Include only if dissociation occurred.)
• Assessment Limitations: [Patient declined safety questions / left before completion / other] (Include only if assessment was limited; note escalation of follow-up.)
• Reference Prior Risk Assessment: [Date] (Include only if unchanged and previously documented.)

Notifications and Coordination

• Disclosure to Patient/Family: [Facts explained]; [Empathy/support offered]; [Unknowns acknowledged]; [How to reach care team]
• Internal Notifications: [Supervising clinician]; [Clinic leadership]; [Risk management/patient safety office] (List names/roles as applicable.)
• External Coordination: [PCP]; [Psychiatrist/therapist/referring clinician]; [On-call coverage] (Specify who was contacted and when.)
• Safety Event Report: [Filed: yes/no]; [Date/time]; [Report number if permitted] (Include only if filed.)
• Mandatory Reporting: [Agency contacted]; [Date/time]; [Brief reason] (Include only if applicable. Do not include root cause analysis or peer-review–protected content.)

Assessment and Plan

Clinical Impression: [Concise summary of reaction: acute panic physiology / dissociative response / trauma activation / possible syncopal episode / other] (State key supporting observations. Avoid causal language; prefer temporal descriptions such as "occurred after induction began.")

• Medical Considerations: [Conditions considered and rationale for/against]; [Tests performed or deferred with rationale]; [Next medical steps if indicated]
• Modifications to Hypnosis Approach: [Defer temporarily / limit to stabilization-only techniques / avoid specific triggers / shorter sessions / slower pacing / explicit stop-signal / increase orientation checks / require in-person / request support person present] (Select and specify as applicable.)
• Additional Supports/Referrals: [Trauma-informed specialist]; [Skills training for grounding]; [Care coordination with existing providers] (Include only if indicated.)
• Medications/Medical Follow-up: [Adjustments or evaluations if indicated]
• Patient Education: [Warning signs reviewed]; [Coping strategies]; [Crisis resources: ED/911/988]; [How to contact clinic]
• Follow-up Plan: [Same-day call / next-day check / next appointment date/time]; [Responsible person by name or role]; [Escalation instructions]; [Outstanding coordination tasks]

(If corrections are needed later, use an addendum rather than overwriting prior entries.)

Addendum

[Addendum content with date/time, author, and reason for update] (Include only when adding information after the original note.)