Patient Behavior Incident Report Form
Use this form to document a patient behavior incident in a healthcare setting and record the immediate response, notifications, and follow-up.
Incident Details
Incident Date
*
 -
Month
 -
Day
Year
Date
Incident Time
*
Hour Minutes
AM
PM
AM/PM Option
Location / Unit / Room
*
Incident Type / Behavior Category
*
Verbal aggression
Physical aggression
Refusal of care
Wandering / elopement risk
Property damage
Self-harm threat
Disruptive behavior
Other
Brief Incident Summary
*
Patient Information
Patient Name
*
First Name
Last Name
Medical Record Number
Current Unit / Ward / Service
*
Please Select
Emergency Department
Inpatient Medical Unit
Inpatient Surgical Unit
Intensive Care Unit
Pediatrics
Maternity
Behavioral Health
Outpatient Clinic
Other
Behavior Description and Contributing Factors
What was the patient doing immediately before the incident?
Observable behaviors exhibited
Aggression
Agitation
Verbal outburst
Noncompliance
Withdrawal
Self-harm behavior
Property damage
Attempted elopement
Other
Known triggers or contributing factors
Pain
Confusion
Frustration
Medication issue
Environmental stressor
Unknown
Other
Were substances, weapons, or unsafe objects involved?
*
No
Yes
Immediate Response and Impact
Staff actions taken immediately
*
Was security, the charge nurse, or a provider notified?
*
Yes
No
Notification time
Names and titles of notified staff
Was the patient or anyone else injured?
*
Yes
No
Injury details
Was any property damaged?
*
Yes
No
Property damage description
Current status of the situation
*
Please Select
Resolved
Ongoing
Escalated
Witnesses and Follow-Up
Witness Name
Witness Role
Recommended Follow-Up Actions
Monitoring
Care Plan Update
De-escalation Plan
Environmental Changes
Counseling
Transfer
Other
Reporter Name
*
First Name
Last Name
Submit Incident Report
Should be Empty: