HC NIRF-01
SECTION G: TYPE OF INJURY (tick one only )
Birth Specific Injury
(Baby)
Apgar score <5@ 1 min &/or;
7@5mins &/or pH ≤ 7.0
Aspiration
Cerebral irritability / neonatal
seizure
HIE - Hypoxic Ischaemic
Encephalopathy with
Hypoglycaemia
HIE Grade 1 - Hypoxic Ischaemic
Encephalopathy
HIE Grade 2 - Hypoxic Ischaemic
Encephalopathy
HIE Grade 3 - Hypoxic Ischaemic
Encephalopathy
Hypoglycaemia - severe
Kernicterus
Neonatal death
Nerve Injury - brachial plexus (incl.
Erbs Palsy)
Nerve Injury - face
Other unexpected deterioration
Stillbirth
Sub-galeal / sub-aponeurotic
haemorrhage
Unknown
Other ____________________
Birth Specific Injury
(Mother)
Death
Hysterectomy (Perinatal)
Incontinence (faecal)
Incontinence (urinary)
Perineal tear
Post-Partum Haemorrhage
Rhesus iso-immunisation
Incontinence (faecal & urinary)
Unknown
Uterine rupture
Other ____________________
Blood Specific Injury
Excessive Bleeding
Fainting
Immunological haemolysis
Febrile non-haemolytic transfusion
reaction
Non-immunological haemolysis
Other ____________________
Diagnosed Disease
Disorder or Cond.
Asbestosis
Cancer
Acute Radiation Syndrome
Narcolepsy/Cateplexy
Hepatitis
HIV
Brucellosis
Legionnaires
Unknown
Dermatitis
TB
Pleural Plaques
Other ____________________
Diagnosed Infection
Clostridium Difficle
COVID-19
CPE
ESBL
Hepatitis
MRSA
Norovirus
Unknown
VRE
VRSA
Other ____________________
General Injuries
Allergic Reaction (incl. anaphylaxis)
Brain Injury / Concussion
Burn / scald / corrosion
Choking / asphyxia
Circulatory / volume depletion
Circulatory / volume overload
Pain/Discomfort
Cut / Laceration / Graze / scratch
Death
Dental injury &/or loss
Deterioration
Haemorrhage
Blister
Malaise / Nausea
Nerve injury / Loss of Function
Puncture / bite
Rash / irritation
Unknown
Other ____________________
Hearing / Sight Injury
Hearing Impairment / loss
Sight Impairment / loss
Tinnitus
Unknown
Other ____________________
Misdiagnosis
Cancer
Fracture
Infection
Unknown
Other ____________________
Musculoskeletal
/ Soft Tissue
Amputation
Bruising
Crushing
Dental Fracture / Tooth loss
Dislocation
Fracture
Repetitive Strain Injury (RSI)
Slipped / Prolapsed Disc
Sprain / Strain
Soft tissue injury
Swelling /
Inflammation
Unknown
Whiplash
Other ____________________
P. Ulcer Stage 1: Intact skin with non-blanchable redness over bony prominence
P. Ulcer Stage 2: Part thickness dermis loss: blister/open ulcer/no slough
P. Ulcer Stage 3: Full thickness tissue loss: +/- visible subcutaneous fat
P. Ulcer Stage 4: Full thickness tissue loss/necrosis: exposed bone/tendon/muscle
Personal Loss
Additional / Further Surgery
Limb Deformity
Defamation of Character
Loss of Wages / Income /
Bus
i
n
e
s
s
Loss of Consortium
Unknown
Organ Retention
Other ____________________
Surgery Specific
Injury
Damage to organ / body part
Dental Damage / Loss
Foreign body left in situ
Unknown
Loss of organ / body part
Nerve injury / Loss of
Function
Inadequate anaesthesia
Unexpected complication /
d
e
te
r
i
o
rati
o
n
Other ____________________
Traumatic/Emotional
Anxiety
/
T
rauma
PTSD
Stress
Unknown
Worried Well
Other ____________________
SECTION F: WHAT WAS THE OUTCOME AT THE TIME OF THE INCIDENT?
Outcome Body Part Affected
Near Miss e.g. Nearly given wrong drug
Category 3
No Injury e.g. Wrong drug given but no harm
occurred
Injury not requiring first aid
Injury or illness, requiring first aid
Injury requiring medical treatment Category 2
Long-term disability / Incapacity (incl. psychosocial)
Category 1
Permanent Incapacity (incl. Psychosocial)
Death
E.g. Arm, Spine, Lung, Other Physiological
