[SA2BDOCTOR]

What is the reason for not documenting INCIDENT REPORT in a patient record?

[Suesquatch]

An incident report is not part of the patient's chart or medical information. It is internal to the facility.

You chart what happened and the interventions and outcomes. You do NOT tip off lawyers and gov't officials as to where to find the facility's private paperwork on it. If they figure out it's there let 'em get it. You don't offer it.

[SA2BDOCTOR]

Thank you for your reponse, you gave me a clear understanding

Originally Posted by Suesquatch

An incident report is not part of the patient's chart or medical information. It is internal to the facility.

You chart what happened and the interventions and outcomes. You do NOT tip off lawyers and gov't officials as to where to find the facility's private paperwork on it. If they figure out it's there let 'em get it. You don't offer it.

[CarVsTree]

Actually lawyers may not look at incident reports at all. Unless you mention them in the chart. Then it becomes part of the medical record.

[Suesquatch]

Originally Posted by suemom2kay

Actually lawyers may not look at incident reports at all. Unless you mention them in the chart. Then it becomes part of the medical record.

Yup.

Don't tell.

[TakeTwoAspirin]

So as not to terrify everyone on the board, someone should mention that the vast majority of incident reports are never used in a legal case against the hospital, employees, or students.

"Incidents" can be very minor "near misses", or failures in procedural guidelines that might have resulted in a mistake that could have caused harm to a patient. The report is completed so that the facility can have a record so that necessary steps can be implemented to amend, change or update the policy with regard to procedures. They can also be used as a measure of quality control for internal purposes. They are most commonly used so that the facility knows where to direct additional training.

They can also be used to report individual staff members for misconduct not related to patient care, for example a doctor using profanity against another staff member, or throwing an instrument in temper in the OR. Generally, stuff not related directly to patient care, but potentially exposing the facility to a complaint or litigation. It allows the facility to 'nip in the bud' problems before they get to litigation (hopefully).

[SAHStudent]

I filed a report as a student 2 semesters ago. The nurses blew it off and said don't worry about it. My instructor and I filed it anyway.

Again, it's not part of the record because that keeps it out of the legal system. You can't even document you wrote an incident report. On a patient side I hate this but I also understand that it can protect the hospital during times when it would be taken wrong.

[elkpark]

I heard this most of my (long) nursing career, also -- "You never document in the chart that you completed an incident report, because doing so 1) makes attorneys aware that the report exists and 2) makes the report part of the client's chart and therefore available to attorneys." I've also heard numerous attorneys (hospital legal counsel as well as plaintiffs' attorneys) say that, while that may have been true once upon a time, it is now basically a hospital old wives' tale -- every attorney on the planet assumes, nowadays, that there is an incident report related to whatever incident they're investigating, and, whether it's mentioned in the chart or not, they can (and do) still request (subpoena) the report along with the rest of the records they request from the hospital and get it. It will end up in (a) case regardless of whether you mention it in the chart or not.

However, it's best to do whatever your employer wants you to, even if there's no real purpose or effect (and isn't that true of so many things we do in nursing! )

[SAHStudent]

Originally Posted by elkpark

I heard this most of my (long) nursing career, also -- "You never document in the chart that you completed an incident report, because doing so 1) makes attorneys aware that the report exists and 2) makes the report part of the client's chart and therefore available to attorneys." I've also heard numerous attorneys (hospital legal counsel as well as plaintiffs' attorneys) say that, while that may have been true once upon a time, it is now basically a hospital old wives' tale -- every attorney on the planet assumes, nowadays, that there is an incident report related to whatever incident they're investigating, and, whether it's mentioned in the chart or not, they can (and do) still request (subpoena) the report along with the rest of the records they request from the hospital and get it. It will end up in (a) case regardless of whether you mention it in the chart or not.

However, it's best to do whatever your employer wants you to, even if there's no real purpose or effect (and isn't that true of so many things we do in nursing! )

My understanding is that this can be true. I have heard of cases where this happens but I've also heard of others where it doesn't because there's no proof the document exists and you can't always get what you can't prove exists.

So keeping it a "secret" can still "protect" the hospital is some cases.

[Daytonite]

Originally Posted by SA2BDOCTOR

What is the reason for not documenting INCIDENT REPORT in a patient record?

I have to tell everyone that what I put into an incident report in the section that said something like "describe the incident" is also almost exactly what I charted in a patient's chart. However, because I was on a safety committee as a nurse manager and we scrutinized every incident report that was made in the facility, there are two very good reasons that I can think of why you don't want to document that an incident report was made.

1. If you document in the chart that an incident report was made, a lawsuit ensues, then that incident report becomes part of the legal documentation
2. The real biggie why you don't want the incident report to become part of the record is that many incident reports are a quality improvement tool and are also used to track and trend accidents. They often have a section on them toward the bottom that ask you something like "how could this occurrence have been avoided?" The answer to that question can pretty much lose any lawsuit for a facility depending on the facts. In the hands of a lawyer during a lawsuit this can be as good as a confession of liability. It can probably open up the opportunity for the lawyer to discover the statistics on similar incidents within the facility. Our committee used to write a final disposition statement regarding each incident on the back of each incident report. Employees never got to see that added statement, but the facility lawyers did. These statements sometimes had to do with any remedial education or follow up that was done with an employee or patient who was the reason for the incident occurring (i.e. forgot to put a siderail up and the patient fell out of the bed, nurse failed to get a second person to help transfer the patient and ended up with a back injury, patient was reimbursed for lost glasses, etc.)