Clinical Reporting Form | Tongue-tie Practitioners

CLINICAL MONITORING FORM

The ATP collates and records all kinds of adverse or unexpected incident reports. This information is submitted by its members anonymously (also no identifiable patient data is included) so that the facts and the figures can be quantified to benchmark and audit, to identify risk factor potential and probability.

This may include:

All bleeding concerns should be reported that requires management (other than infant feeding to stem bleeding).
Adverse or unusual reactions.
Infections.
Additional medical interventions.
Any unusually occurring ‘event’ or anomaly.
Complications.

This is for ATP monitoring and audit which is separate to a CQC notification.

CQC Notification requirements are listed and submitted on their website through your provider portal:

Notifications - Care Quality Commission (https://www.cqc.org.uk/guidance-providers/notifications)

Clinical Monitoring Form

Practitioner Name:

Email:

Date of Incident:

Venue of Incident:

What setting was the infant treated in?:

Age of Infant:

What 'type' of tongue tie restriction was the infant treated for?:

Has the infant received Vitamin K?:

Summary oof incident:

What immediate action was taken?:

Were any other healthcare professionals involved in subsequent care?:

What was the initial outcome?:

Was the infant transferred to an NHS Hospital?:

What was the final outcome?:

Would you like the opportunity for a debrief?:

Has a debrief already been completed?:

Please use this space to include any additional information that you feel may be relevant:

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I agree

Clinical Monitoring Form

Thank you for submitting this form.

You will receive an automated Email confirming receipt of submission.

The Email receipt includes your full submission should you wish to use it in your records.

If you would like to discuss your adverse event with a member of the ATP support team please email support@tongue-tie.org.uk (MEMBERS ONLY)

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