Aquatic Session Incident/Adverse Event Note

Date/Time of Documentation: [Date and time] (If documenting after the fact, begin narrative with "Late Entry/Addendum:" and anchor all events to actual times.)

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

Location: [Facility name]; [specific pool area: deck / ramp / locker room / stairs / lift / pool basin / other]

Author/Credentials: [Name, credentials, role]

Patient: [Name / MRN / DOB per policy]

Event Summary

Event Type: [fall / near-syncope / syncope / seizure / wound issue / aspiration-choking / equipment malfunction / other]

Severity: [no harm-near miss / minor injury / required treatment / required ED transfer-higher level of care]

Witnessed: [yes / no / partially]

(Use objective, neutral language. Attribute non-observed information to source. Use explicit timestamps. Include pool-specific environmental details when relevant. Do not speculate about cause or assign fault.)

• [Time] Pre-event context: [activity, assistance level, patient position, entry/exit method, handrail use, footwear, surface condition, other relevant setup]
• [Time] Event onset/discovery: [how the event was first noticed, by whom (name/role), patient statement if applicable, unwitnessed details noted as unknown]
• [Time] Sequence of events: [step-by-step factual description including impact/contact points, water exposure, observed movements, device/equipment status as applicable]
• [Time] Immediate post-event course: [patient position/status, symptoms, level of assistance required, safety measures implemented]

Assessment

General/Mental Status: [appearance, level of distress, orientation, speech, behavior, post-ictal features if applicable]

Vitals: [BP, HR, RR, SpO2, Temp, Glucose as indicated] (Required for near-syncope, syncope, fall with potential injury, seizure, respiratory symptoms, or escalation. If not obtained, state why.)

Focused Exam: [pertinent findings by system—neuro, MSK, skin/wound, respiratory as indicated] (For falls/impact events, include head strike: [yes / no / unknown] and LOC: [yes / no / unknown]; duration: [if applicable]. Do not infer negatives; use "unknown" when not elicited.)

Serial Reassessments: [Time and updated findings for each reassessment, if performed]

Interventions

Actions: [Time] [Safety actions, first aid, clinical interventions, positioning, wound care, glucose administration, oxygen/airway support, seizure precautions, EMS activation, etc.]; Performer: [name/role] (If no treatment required, state explicitly.)

Patient Response: [improved / worsened / symptoms resolved / persistent deficits]; [objective changes]

Disposition & Follow-Up

Notifications: [Who notified (role/name), time, method, information communicated, orders/guidance received]

Final Status: [symptoms resolved/persisting, neuro status, pain controlled, wound status, tolerance of ambulation if applicable]

Disposition: [returned to therapy / observed on-site / sent home with caregiver / transferred to ED / EMS transport]

Follow-Up Plan: [monitoring instructions, medical follow-up required and timeframe, therapy modifications for future sessions, responsible person for follow-up]

(If patient declined recommended evaluation or transfer: document capacity assessment, risks explained, patient's stated reasoning, understanding confirmed, return precautions provided.)

Contributing Factors: [Environmental, equipment, or process factors factually observed]; [immediate preventive actions taken] (Do not reference internal incident reports or quality review processes.)