Adverse event report

Allows patients to report a possible adverse event related to their treatment in free text.

Specialties: general_practice|Areas: general

Time:2 min
Pages:1
Questions:1
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Example Assessment Result

Patient-Reported Outcome Measure

Total Score
72/100
Clinical InterpretationModerate Function
Section 1
Completed (8/10)
Section 2
Completed (7/10)
Remaining sections
All responses submitted
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TimingBaseline
Date15 Jan 2024
Score65
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About the Adverse event report

A generic free-text capture form that allows patients to report a possible adverse event in their own words. It is not a validated clinical instrument and does not apply any scoring, severity grading, or causality assessment - it is intended purely to let patients flag a concern for clinical follow-up.

Prevalence:
common

Medical Specialties

General Practice

Anatomic Areas

General

Clinical Indications

Adverse Event Reporting
Treatment Safety Reporting

Administration Instructions

Please describe what happened, when it occurred, and any action taken. Include as much detail as you can.

Scoring Methodology

This form is not scored. The response is stored as free text only.

Scoring:
Lower is better

Clinical Limitations & Considerations

This is an unstructured, unscored capture field and does not itself perform safety triage, severity grading, or causality assessment. Structured adverse event fields and safety routing are handled by separate, dedicated processes.

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This questionnaire is provided free of charge. Patient Watch charges only for platform services (data storage, automated reminders, analytics) - not for use of clinical instruments. This non-commercial model supports academic and clinical use.View full licensing disclosure