INAs in the chart?

[Sbrewster]

I recently started at my current job in a LTC facility, and I can remember all throughout my CNA career and through nursing school that incident reports are to stay FAR away from a residents chart. Don't mention them in the chart, don't put them in the chart, they are ONLY for the facility. But this facility I started working for requires you to put all of the residents' INAs Aaand unusual occurrences inside their chart.

I found that weird! Does anyone else know of work somewhere where they require this?? I was always taught it was a big no no!

[chrisrn24]

Obviously chart that the incident occurred in the progress notes but don't write "incident report completed." Does that make sense? You can have a copy of the incident report in the chart but don't mention it in the progress notes.

[CapeCodMermaid, RN]

Most facilities consider incident reports to be INTERNAL CQI documents and not part of the medical record. If it's mentioned in a note, an attorney can have access to it. We are electronic so we do our incident reports on the computer, but they are stored in a part of the record very few people have access to.

[Jester05]

The unusual occurrences are ok, lets say you have a resident who the family will swear up and down doesn't walk but at 230 am she gets up and is found in another hall, document cause if something happens to her there is a record of her "behaviors", now the incident report is kinda weird, is it the FULL incident report or just a "record" of the incident occurring, these are 2 different types of documentation. In TX we don't mention or file incident reports in the chart, we document thoroughly. It doesn't hurt to ask your ADON or your medical records or MDS nurse.

[morte, LPN, LVN]

do you have pointclickcare?

Most facilities consider incident reports to be INTERNAL CQI documents and not part of the medical record. If it's mentioned in a note, an attorney can have access to it. We are electronic so we do our incident reports on the computer, but they are stored in a part of the record very few people have access to.

[aortas]

our incident reports don't go in the cart. you do obviously have to document an incident as it occurred, which at times seems repetitive to place in an incident report and a nurses note.

however, charting something like: "during am care on date and time in room 1, cna j observed hematoma to pt x L hip, upon assessment of pt x by this nurse, observed hematoma to L hip, 10x12 cm. L hip of pt x warm to touch, eccymotic, c/o pain upon palpation. pt unable to state where hematoma occurred. pt unable to extend L leg. medicated with pen tylenol at time, ineffective, as pt co of severe pain after admin, perch 5/325 given per physician order of severe pain. MD/family made aware." the charting often reflects whats on the incident report, but you'd never end your charting saying, "MD/family made aware. incident report filed."