| 74081-1 | Patient safety event:ID:Pt:^Event:Nom:AHRQ | required |
| 30947-6 | Date form completed | required |
| 74724-6 | Best description of the event or unsafe condition:Find:Pt:^Event:Nom:AHRQ | required |
| 74723-8 | Device involved in patient safety event or unsafe condition:Type:Pt:{Device}:Nom:AHRQ | required |
| 74722-0 | At the time of the event, the device was placed within the patient's tissue:Find:Pt:^Patient:Ord:AHRQ | conditional |
| 74721-2 | Event resulted in the device being removed:Find:Pt:^Event:Ord:AHRQ | conditional |
| 74720-4 | Device name | optional |
| 74719-6 | Manufacturer name | optional |
| 74718-8 | Device ID | required |
| 74717-0 | Model # | conditional |
| 55081-4 | Product version code:ID:Pt:Software:Nom: | conditional |
| 74716-2 | Vendor firmware version | conditional |
| 74715-4 | Serial # | conditional |
| 74714-7 | Lot or batch no. | conditional |
| 74713-9 | Other UDI [Type] | conditional |
| 74726-1 | Other UDI | conditional |
| 74712-1 | Expiration date | conditional |
| 74711-3 | UDI | conditional |
| 74710-5 | Asset tag number | conditional |
| 74709-7 | Device intended for single use was involved in the event or unsafe condition:Find:Pt:^Event:Ord:AHRQ | required |
| 74708-9 | Device intended for single use was reused in the event or unsafe condition:Find:Pt:^Event:Ord:AHRQ | conditional |
| 74707-1 | Medication or other substance was involved:Find:Pt:^Event:Ord:AHRQ | required |
| 74706-3 | Health information technology device was involved:Find:Pt:^Event:Ord:AHRQ | conditional |
| 74705-5 | Best characterization of health information technology device:Find:Pt:{Device}:Nom:AHRQ | conditional |
| 74704-8 | Administrative or billing system component:Type:Pt:Administrative or billing system:Nom:AHRQ | conditional |
| 74703-0 | Electronic health record system component:Type:Pt:Electronic health record:Nom:AHRQ | conditional |
| 74702-2 | Circumstances involving the health information technology device in the event or unsafe condition:Type:Pt:{Device}:Nom:AHRQ | conditional |
| 74701-4 | Problem that resulted from the equipment or device function problem:Type:Pt:{Device}:Nom:AHRQ | conditional |
| 74700-6 | Ergonomics or human &or device interface issue:Type:Pt:{Device}:Nom:AHRQ | conditional |
| 74725-3 | Patient safety event report - hospital - device or medical &or surgical supply, including health information technology - version 1.2:-:Pt:^Patient:-:AHRQ | |