| 74081-1 | Patient safety event:ID:Pt:^Event:Nom:AHRQ | required |
| 30947-6 | Date form completed | required |
| 74500-0 | Age at time of event:Find:Pt:^Patient:Nom:AHRQ | required |
| 74694-1 | Ethnicity:Type:Pt:^Patient:Nom:AHRQ | required |
| 74693-3 | Race:Type:Pt:^Patient:Nom:AHRQ | required |
| 52797-8 | Dx ICD code | optional |
| 74562-0 | Rescue intervention was attempted:Find:Pt:^Patient:Ord:AHRQ | required |
| 74561-2 | Documented rescue interventions:Type:Pt:^Patient:Nom:AHRQ | conditional |
| 74560-4 | Extent of harm to the patient:Find:Pt:^Patient:Nom:AHRQ | required |
| 74559-6 | Anticipated duration of harm to the patient:Find:Pt:^Patient:Ord:AHRQ | required |
| 74558-8 | Timing of harm assessment:Find:Pt:^Patient:Ord:AHRQ | required |
| 74557-0 | Increased length of stay due to incident:Find:Pt:^Patient:Ord:AHRQ | required |
| 74556-2 | Family or guardian was notified:Find:Pt:^Patient:Ord:AHRQ | required |
| 74502-6 | Patient safety event report - hospital - patient information form - version 1.2:-:Pt:^Patient:-:AHRQ | |