Photocopy of incident report

  1. I recently "wrote myself up" regarding an incorrect sliding scale dosage (due to poor doctor handwriting grrrr...but that's another thread!) The nurse that double checked the dosage also signed it. Later she handed me a copy of the report. I guess a lot of nurses make their own copies just in case the issue ever comes back to them. I discreetly asked a charge nurse if this was Kosher and she replied that "It wouldn't be a bad idea...those things always come back to bite you." The nurse who gave it to me takes hers home and I wondered about patient confidentiality. I thought about keeping it in a file in my employee locker but someone said if anyone found out about it it could be supeoned if a suit were ever brought and the plaintiff's lawyer found out about it. I know that if I were ever questioned I could not lie that I had a copy....so I ended up shredding it. I'm pretty sure it's against my hospital's policy to photocopy incident reports but I'm reluctant to ask because I don't want to get anyone in trouble. Has anyone ever heard of this practice and what do you think?
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  2. 16 Comments

  3. by   huckfinn
    YOU WERE RIGHT TO SHRED THE PAPERS. This is a breach of confidentiality and soon if not already against the law. It is never a good idea to collect evidence against yourself to turn over later.

    Go to your patient relations, risk management or other titled department in your institution and ask "off the record" questions like this to them. Set up hypothetical situations like the one you mentioned here and see what kinds of faces they make and you will have the real answers you seek.

    Good luck!
  4. by   nursedawn67
    I only copy papers if it pertains to myself....such as vacation requests or notes that required a reply, I copy those after I put the reply on it. I have never copied anything with patient info on it, and I suppose if I were to do it, I would black out names. but so far have never copied anything like that.
  5. by   whipping girl in 07
    If it were me, I would keep a copy and never let anyone know about it! The hospital will not back you up if something happens to this patient and they get sued. If you have a copy then you at least have something to refer back to regarding the incident. If the patient/family decides to sue the hospital, they can supoena the patient's medical record. The incident report is not part of the medical record, from what I understand, but rather part of the personnel file of the person written up. So I'm not sure that the lawyers could get a copy of it, unless the hospital decides to hand over some personnel files of involved employees to hang them out to dry. Maybe I'm too young to be such a cynic, but I believe it is important to protect yourself.

    I'm a recent grad, and I had more than one nursing school instructor tell us to keep such copies. You can also keep a journal about your patients (at least, those that could end up being problematic). As long as you keep your secret stash a SECRET, you should not have to worry about it being supoenaed.

    JMHO.
  6. by   kids
    I have always copied every incident report that related to me. I black out the patient name and any other identifiers except the patient number and facility name, I then recopy the copy, then I shred copy #1. That way there is no breach of confidentiality as the identifing information can not be read from behind by holding it up to the light as it can with white out, or by scraping off the white out or through black marker by holding it with the light casting across it. I was told to do this in school and it has saved my a$$ a couple of times:

    I was injured 2 in different incidents in a 2 week period in the locked unit of the same facility by the same geri-psych patient, once when she threw a chair at me, the other when she pushed over a loaded 6 foot bookcase that had not been secured to the wall...I caught it before it fell on a wheelchair bound patient...2 years later when L&I finally decided it was a new injury and not an aggrevation of a previous injury (my back) the employer denied that any incidents had even occured...they paid a hefty fine to the State when I produced the incident reports signed by witnesses...including the then shift supervisor who was DNS at the time the incidents were denied (same administrator also)

    Another time we had a glucoscan machine that appeared to be faulty. Together another Nurse and I confirmed that the memory on the machine was faulty and was randomly deleting patient and calibration test results. Admin was less than sympathetic...we filled out an incident report. 3 weeks later we were both fired and reported to the BON for falsifying glucoscan results because an evening Nurse who didn't like the fact she couldnt 'boss' us around (horizontal harrassment) had been checking the numbers we recorded in the MAR against the memory in the machine and had prepared a detailed report of her "investigation". Thanks to my copy of the incident report (original had been round filed as a 'non-incident') the other Nurse and I were both cleared by the BON and paid our lost wages for the period of time we were unemployable due to the open and active complaints against our licenses (the Corporation was happy to write us checks after we produced the clearance from the board, the incident report and a letter from an attorney-do not screw with my family or my livelihood).

    As with anything...CYA

    -nancy
  7. by   donmurray
    Go! Nancy! The perfect reply.
  8. by   Agnus
    Nancy, THANK YOU.
  9. by   BadBird
    Nancy,
    Thanks for the new insight, I never thought to copy anything but my schedule but from now on I will .
  10. by   mcl4
    Originally posted by BadBird
    Nancy,
    Thanks for the new insight, I never thought to copy anything but my schedule but from now on I will .

    The question still has not been answer which would be is this against hospital policy to copy incident reports. This is not something I've seen done in the many years I've been a nurse by myself or others? This was not taught by the nursing instructors I was under years ago?
  11. by   babsRN
    I have always understood that occurance reports should never be copied. But also I need to mention what our risk manager advises about journal keeping or copying other items related to caring for patients. All of these can become evidence and are discoverable during a lawsuit. Only when they are "work product" can they be excluded. This includes any note taking during meetings about a potential case. I've learned not to take notes, and have refrained from any journal keeping about events of each day. Has anyone else received this type of advice?
  12. by   P_RN
    Since I would write nothing but the truth, I would have no problem keeping a journal.

    And I will tell you that more than once I have seen occurrence reports the *I* had written, reappear with "new information" supposedly written there by me!! Now how legal is THAT? Yet it happens.

    I have also been told to fill in the blanks on other's reports, and been threatend when I refused.

    For awhile I used a FOUNTAIN PEN just to try to make what I wrote hard to fake. You're damned if you do and damned if you don't but *I* will continue to photocopy ANYTHING that pertains to ME and they can bump it if they don't like it. It has saved the day for me more than once.

    I notice that attorneys sign things in BLUE just to make their signature more identifiable.
  13. by   NurseDennie
    At "my" hospital, it's policy not to photocopy incident reports. As a matter of fact, it says right on the form not to copy it. My response is that if I wrote it, I own it. When I have copied them, it's been with a piece of paper over the patient information, and just copied my notes part of it.

    I've never heard any advice one way or the other about journals, etc. I understand that the incident reports are NOT part of the patient's medical records, but I'll bet that attorneys can subpoena everything they know or think exists.

    Can someone subpoena all of your personal, at-home type paperwork, or do they have to know what they're looking for? It seems to me that nobody could force you to bring in all your papers just on the chance that you have a journal.

    Love

    Dennie
  14. by   Huganurse
    Depending on what agency or court level you are talking about and why they are doing it, the answer is yes, they can subpoena or search for anything they want. Even things that you may consider your own personal property.

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