| 74081-1 | Patient safety event:ID:Pt:^Event:Nom:AHRQ | required |
| 30947-6 | Date form completed | required |
| 30947-6 | Date form completed | required |
| 74079-5 | Event:Type:Pt:^Event:Nom:AHRQ | required |
| 74555-4 | Event discovery date & time:TmStp:Pt:^Event:Qn: | conditional |
| 74554-7 | Description of patient safety event or unsafe condition:Find:Pt:^Event:Nar:AHRQ | optional |
| 74553-9 | Location of patient safety event or unsafe condition:Find:Pt:^Event:Nar:AHRQ | optional |
| 74552-1 | Categories associated with patient safety event or unsafe condition:Find:Pt:^Event:Nom:AHRQ | required |
| 74772-5 | Patient information:-:Pt:^Patient:-:AHRQ | |
| 74551-3 | Perinatal incident that affected a neonate:Find:Pt:^Event:Ord:AHRQ | optional |
| 74771-7 | Neonatal patient information:-:Pt:^Patient:-:AHRQ | |
| 74770-9 | Reporter information:-:Pt:^Event:-:AHRQ | |
| 74495-3 | Patient safety event report - hospital - healthcare event reporting form - version 1.2:-:Pt:^Patient:-:AHRQ | |