Get the free Source Needlestick Form - University Medical Center New - umcno

Source Needle stick Form Employee blood / body fluid exposure instructions: Place SOURCE Patient Label in Box Below Act fast! You have a one two-hour window to complete this process. 1. Place patient

How to fill out source needlestick form

How to fill out source needlestick form:

1. Carefully read the instructions: Start by thoroughly reading the source needlestick form and any accompanying instructions. This will ensure that you understand the purpose of the form and the information you need to provide.
2. Provide personal information: Fill in your personal details, such as your name, contact information, and employee ID, if applicable. This helps establish your identity and ensures that the form is properly associated with you.
3. Describe the incident: Explain the details of the needlestick incident, including the date, time, and location. Be as specific and accurate as possible to provide a clear record of what happened.
4. Identify the source: Indicate the source of the needlestick, whether it was a specific patient, medical device, or contaminated object. Include any relevant information, such as the patient's name or the type of medical procedure being performed.
5. Document your actions: Describe the immediate steps you took following the needlestick incident, such as washing the affected area, reporting to a supervisor, or seeking medical attention. This helps to demonstrate that proper procedures were followed and can aid in any necessary follow-up actions.
6. Provide additional details: If there are any additional details or relevant information regarding the incident, include it in the appropriate section of the form. This might include witnesses, any potential exposure to bloodborne pathogens, or any other relevant circumstances.
7. Sign and submit the form: Once you have completed all the required information, sign the form to certify its accuracy. Follow the designated procedures for submitting the form, whether it is to your immediate supervisor, the human resources department, or another designated authority.

Who needs source needlestick form?

1. Healthcare professionals: Doctors, nurses, laboratory technicians, and other healthcare professionals who may come into contact with needles or sharps during the course of their work frequently require source needlestick forms. This helps to document and address any potential occupational exposure to bloodborne pathogens.
2. Laboratory workers: Individuals working in research laboratories, diagnostic laboratories, or other settings where the use of needles is common are also likely to need source needlestick forms. These forms can facilitate the reporting and investigation of needlestick incidents in these environments.
3. Emergency responders: Paramedics, firefighters, and other emergency responders who may encounter needles or sharps in the field may require source needlestick forms. These forms help to ensure proper documentation and management of any needle-related injuries or exposures that occur on the job.

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