Sample Wound Infection/Unexpected Outcome Report

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As part of Lakeland (Fla.) Surgical & Diagnostic Center's efforts to comply with regulatory and reporting requirements, the ASC asks its physicians to report any unexpected patient outcomes and post-operative wound infections. It also asks about the type of treatment needed as the result of these outcomes.


Every month, physicians are sent a patient list of procedures performed and are asked to fill out a report that asks how many, if any, unexpected outcomes and would infections there were; for each unexpected patient outcome or post-operative wound infection, the physician is asked to full out an individual report about the incident.


Any unexpected outcomes or wound infections report to the ASC are investigated and results communicated to the center's Quality Improvement and Medical Advisory Committee.


To download a sample copy of the wound infection/unexpected outcome report sent to physicians, click here (doc).


Learn more about Lakeland Surgical & Diagnostic Center


Download other sample forms for adaptation and use in your ASC:


- Sample Medication Reconciliation Form


- Sample ASC Adult PONV/PDNV Policy


- Sample ASC Time-Out Policy and Procedure

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