Medical Harm Timeline
& Record Organizer

Describe a Serious Hospital Injury, Unsafe Event, or Fatality

Purpose:

This questionnaire is designed to help patients and families organize important information about a serious hospital event. Save and print the document for your records. The form uses check boxes and short-answer sections to help individuals describe what happened in a structured, brief way. No optional personal data will be revealed to any third party at any time.

1

Patient Information

Gender
Person Completing This Form
2

Hospital Information

Type of Admission (Check all that apply)
Department(s) Involved (Check all that apply)
3

What Happened?

What was the most serious and harmful event? (Check all that apply)
4

Outcome

Outcome (Check all that apply)
5

Doctors and Staff

1.
2.
3.
1.
2.
3.
Did any staff member say something that concerned you?
6

Warning Signs & Concerns

Did the patient or family warn staff that something was wrong?
Were concerns ignored or minimized?
Which concerns were raised? (Check all that apply)
7

Discharge & Follow-Up

Was the patient discharged unexpectedly or too early?
Was the patient discharged to:
Was the patient able to safely care for themselves at discharge?
Did staff explain discharge instructions clearly?
8

Medical Records & Evidence

Have you requested medical records?
Do you currently possess: (Check all that apply)
9

Complaints

Have complaints been filed with: (Check all that apply)
10

Timeline of Events

11

Additional Concerns

Did you observe any of the following? (Check all that apply)
12

Final Comments

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