Incident/Adverse Event Report (Reflexology)

Confidentiality & Use

Confidentiality statement: [Quality/Risk Management—Confidential; not part of the clinical record / Incident documentation—objective facts only; avoid speculation and blame]

(Select confidentiality statement according to organizational policy. Clinical care delivered must also be documented in the client's session note per organizational policy.)

Report Information

• Event Classification: [Incident / Near miss / Unsafe condition]
• Date & Time of Event: [Date and time of event]
• Date & Time Discovered (if different): [Date and time discovered / Not applicable]
• Date & Time Report Completed: [Date and time of report completion]
• Location: [Facility name, room or area]
• Service Setting: [Clinic / Home visit / Event / Other]
• Reporter Name & Role: [Reporter name and role]
• Other Staff Present: [Names and roles / None]
• Supervisor on Duty: [Name / Not applicable]

Client Information

• Client Name: [Client full name]
• Date of Birth: [DOB]
• Client ID: [Client ID / Not available]
• Contact: [Phone and email]
• Emergency Contact: [Name, relationship, phone]
• Guardian: [Name, relationship, contact / Not applicable] (Include if minor or dependent adult.)
• Interpreter Used: [Y / N] (If yes, include language and interpreter name or ID.)

Session Context

(Briefly describe what was occurring when the event happened. Only include intake details directly relevant to understanding the event.)

• Appointment Type: [Initial / Follow-up]
• Session Start Time: [Session start time]
• Reflexology Approach: [Feet / Hands / Ears] — [General relaxation / Targeted protocol]
• Client Position at Time of Event: [Supine / Seated / Side-lying / Standing / During transfer]
• Products Applied to Skin: [None / Product name, brand, lot number if relevant to event]
• Equipment in Use: [Chair / Table / Stool / Foot basin / Other]
• Relevant Intake Highlights: [Relevant intake details / None noted] (e.g., fasting, history of orthostatic symptoms, skin sensitivity, pregnancy)

Event Description

(Provide a chronological, time-stamped timeline of objective observations. Document who observed each item, use quotation marks for client statements, and note immediate context. For unwitnessed events, describe how discovered and mark mechanism as "Unknown" unless directly observed.)

• [Time — Objective observation, observer, immediate context, direct quote if applicable]
• [Time — Subsequent observation or action, observer, client response]
• [Time — Ongoing monitoring, changes noted]
• (Add additional time-stamped entries as needed to maintain full chronology.)

Assessment Findings

(Use specific, observable findings. Include timestamps. If assessment not performed, document "Not assessed" with brief reason.)

• Symptoms reported: [Time — Symptoms reported with quotes if stated] (e.g., dizziness, nausea, shortness of breath, sweating, weakness, pain, itching, numbness)
• Pain score and location: [Time — Score 0–10, location / Not assessed — reason]
• Skin findings: [Time — Location, size, color, warmth, integrity; photos taken Y/N]
• Injury findings: [Time — Head strike Y/N/Unknown, bleeding, bruising, deformity, ROM limits, new neurologic symptoms / Not applicable] (Include if fall or impact.)
• Mental status and mobility: [Time — Alertness, orientation, coherence, ambulation independent or with assistance]
• Vital signs: [Time — BP, HR, RR, SpO2, position / Not assessed — reason]

Actions Taken

(Time-stamped list of interventions and client responses.)

• [Time — Session modification: stopped, ended early, reduced pressure, other]
• [Time — Safety actions: assisted to seated or supine, cleared hazards, stayed with client]
• [Time — Comfort measures per policy: water, cool compress, positioning, other]
• [Time — Monitoring: repeat vitals, symptom reassessment]
• [Time — Escalation: notified supervisor, recommended urgent evaluation, activated EMS]
• [Time — Equipment or product handling if implicated: removed from use, lot number retained]

Notifications

(Structured log of who was notified, when, and the outcome.)

• Client informed: [Time — Observations and recommendations communicated, client response]
• Emergency contact: [Y / N] [Time, outcome]
• Supervisor or Manager: [Name, time notified, guidance received]
• Other provider: [Provider type, client consent Y/N, time, information shared / Not applicable]
• EMS: [Time called, arrival time, disposition / Not activated]

Refusal of Recommended Care

(Include if client refused recommended escalation such as EMS or medical evaluation.)

• Recommended action and symptom-based reason: [Recommendation and rationale]
• Client stated reason for refusal: [Quote if possible]
• Observed capacity: [Alert / Oriented / Coherent]
• Return precautions provided: [Precautions summarized, written instructions given Y/N]
• Witness to refusal: [Name and role / None]

Outcome & Disposition

• Client condition at conclusion: [Resolved / Improved / Persistent] — [Objective markers: vitals, gait stability, symptom report]
• Disposition: [Returned to session / Session ended / Left independently / Escorted / Picked up by emergency contact / Transferred to EMS]
• Items provided: [Written instructions / Ice pack per policy / Other / None]
• Follow-up scheduled: [Y / N] [Date and time / To be determined]

Contributing Factors

(Objective observations only—no speculation or blame. Mark "Unknown" if not observed or verified.)

• [ ] Environmental conditions: [Wet floor / Clutter / Lighting issues / Trip hazards / Other / Unknown] — [Brief note]
• [ ] Transfer factors: [Client footwear / Assistive device / Assistance provided / Transition speed / Other / Unknown] — [Brief note]
• [ ] Equipment issues: [Chair instability / Table height / Malfunction / Other / Unknown] — [Brief note]
• [ ] Product factors: [Brand, lot, expiration, application site / Unknown] — [Brief note]

Severity Classification

• Event reached client: [Y / N]
• Harm level: [No harm / Mild / Moderate / Severe]
• Additional outcomes: [Required monitoring only / Required outside medical evaluation / Hospitalization reported / None]
• Brief rationale: [1–2 line rationale tied to observed outcomes without implying causation]

Attachments

• [ ] Relevant intake form excerpt
• [ ] Consent confirmation
• [ ] Photos [Storage location, consent documented per policy]
• [ ] Product label or lot number photo
• [ ] Witness statement(s)
• [ ] EMS documentation

Follow-Up Plan

• Planned follow-up contact: [Timing, responsible staff]
• Recommendation to seek medical evaluation: [Symptom-based recommendation, client acknowledgment / Not applicable]
• Planned session modifications: [Shorter duration / Slower transitions / Product avoidance / Other / None]

Authentication

• Reporter Signature: [Name, credentials if applicable]
• Date/Time: [Date and time]
• Supervisor Review Signature: [Name / Not required]
• Date/Time: [Date and time]
• Report Status: [Open / Closed]

(Corrections or new information must be added as dated, time-stamped addenda; original entries should not be overwritten. Use neutral phrasing such as "Client reported...," "Observed...," "Found...," "Per witness..." Avoid causal statements or diagnoses outside scope.)