Telemedicine Malpractice Incident Report Form
Report Date
Reporter Name
Contact Information
Patient Name or ID
Date of Incident
Time of Incident
Location (e.g., platform, app, clinic)
Healthcare Provider(s) Involved
Type of Malpractice Incident
Misdiagnosis
Delay in Treatment
Breach of Privacy
Prescription Error
Technical Failure
Other
Description of Incident
Pertinent Details / Sequence of Events
Immediate Actions Taken
Witness(es) (if any)
Attachments (e.g., screenshots, documents)