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Physiotherapy New Zealand - Patient Adverse Event Reporting

Completing this survey will allow Physiotherapy New Zealand to monitor adverse reactions/events and inform the establishment of best practice in physiotherapy care.

If you need to download a copy of this information, you must do so BEFORE selecting DONE. If you are using Chrome or Internet Explorer right click on the page and select 'Print'. Either print a hardcopy of the form or change the printer to 'Save as a PDF' to save an electronic copy. If you are using Firefox please follow the process here.



1. Years of postgraduate physiotherapy experience using the modality to which the adverse incident relates e.g. acupuncture, taping


2. Postgraduate qualification - please select your highest level of qualification


3. What was the age of the patient affected by the adverse reaction?


4. What was the gender of the patient affected by the adverse reaction/ event?


5. What was the diagnosis/ presenting complaint of the patient affected by the adverse reaction/event?


6. Please state below any relevant medical history of the patient affected by the adverse reaction/event


7. Treatment provided


8. Type of adverse reaction/ event


9. Brief description of the event


10. Action Taken (e.g. additional medical treatment, X-ray, advice, onward referral to specialist)


11. Outcome (including permanent consequences, loss of function etc)


12. ACC treatment injury claim lodged? (ACC should be notified if serious adverse reactions/ events occur)


13. Insurers notified of incident? (Professional liability insurers e.g. AON, should be notified of serious adverse reaction/events)


14. If the adverse event relates to taping, please enter the type of tape below (otherwise skip to question 15)


15. If the adverse reaction/ event relates to acupuncture please complete the following question (otherwise skip to question 16)


16. If the adverse reaction/ event relates to Manipulation/ mobilisation please complete the following question (otherwise skip to question 17/ complete the survey)


17. Is there anything that could have beeen done differently to avoid the adverse reaction / event?


18. Any further comments?

If you need to download a copy of this information, you must do so BEFORE selecting DONE. If you are using Chrome or Internet Explorer right click on the page and select 'Print'. Either print a hardcopy of the form or change the printer to 'Save as a PDF' to save an electronic copy. If you are using Firefox please follow the process here.