Incident reports

Specialties Geriatric

Published

UGH...our incident report is about 15 pages long. If we find a bruise we are supposed to fill out the whole 15 pages! Then, we are expected to do an investigation...interview EVERYONE who had contact with the resident until we find someone who can tell us what happened. It is so time consuming and demeaning that lots of the nurse's aides have told me they will no longer report bruises. I know abuse is a terrible thing, but are we going overboard???

Any one with a one or two page incident report?

I recently went to an inservice and one of the things that was stressed (by a legal professional) was to keep the incident report as simple as possible - 1 page, 1 side. Then put the follow-up and investigations, etc. on separate forms that are specifically designated as QA - the incident report can be used in a court of law. The QA reports are protected. I'm looking now for a good 1-page report. Anyone have one?

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Specializes in Gerontology, Med surg, Home Health.

After 5+ years of using a 12 page incident report (no joke) my company has just gone to a 1 page plus two pages for investigation. We have separate forms for falls, bruises, and med errors. The compliance rate for filling the form out has more than doubled since now it only takes a few minutes. You probably could make up your own form or look through a Briggs catalog...they seem to have a form for every occasion.

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After 5+ years of using a 12 page incident report (no joke) my company has just gone to a 1 page plus two pages for investigation. We have separate forms for falls, bruises, and med errors. The compliance rate for filling the form out has more than doubled since now it only takes a few minutes. You probably could make up your own form or look through a Briggs catalog...they seem to have a form for every occasion.

Thanks! That's exactly what we're trying to do here - our Safety manager is in the process of checking Briggs for the type of form we want - are your forms also from Briggs or did you create your own?

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Specializes in Gerontology, Med surg, Home Health.

Our corporation developed the form I think, but you could easily develop your own.

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Specializes in MS Home Health.

Gosh I have no room to complain over our two page one!

renerian :chair:

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I'm in New York state. The incident report itself is 2 pages, but then we have to go back 3 shifts prior (including current shift, so that's 4 shifts total) and have everyone who was on the unit sign a statement. So it ends up looking like a phone book by the time you're done. Even the people who had no contact with that resident have to fill out a statement form, saying" I had no contact with that resident on such-and-such shift, such-and-such date....." Talk about a waste of paper!!!:eek:

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We have a one sided incident form, which includes the front/back image of the resident where you can mark on the body where the skin tear, bruise, etc. is located. If the incident is witnessed, the cna (or whoever witnessed the event) fills out a witness statement and it is attached to the incident report. The reports are then followed up on accordingly. Many of the nurses used to gripe about having to fill them out...and the resident's primary nurse is responsible for obtaining the residents vital signs immediately after the incident. Many of the nurses try to get the cna's to do the vs for them. I don't think I'll complain again, after hearing that some of you have PAGES to fill out!!! I sound pretty lucky!!

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Lets see...

is it a fall, is it an injury, was it witnessed,

was it a med error, did staff get hurt, was it resident to resident, etc, every one of these variables changes what paperwork we fill out, who it goes too. I almost would like a twelve page form that you could just mark not applicable instead of searching out all the different papers. At one point we had packets with "everything" in them. You threw half of it away and had to look for paperwork that wasn't in it.

As for statements, well I ask for them but if I don't get them I figure it is the person who is doing the 5 day follow up's responsibility.

Now we are doing weekly skin checks that every single skin discoloration mole etc must be documented. So CNAs not turning in bruises is a moot point. Once a week it will get documented. (and probably get an incident report too)

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It's to the point where nurses are almost afraid to thoroughly assess the residents because of fear of the paperwork that results when they find the smallest "incident" on their skin. It also sucks to have to call the physician in the middle of the night and inform them. "Mrs. S has a small scratch on her leg. I think she had an itch." I'm sure the doctors love that.

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I think that the location of the bruise is more of a concern vs. a bruise in general. I mean with elderly that are Coumadin they bruise easily not to mention the bruises from venipunctures! I have patients who have them on their arms and hands from all the blood draw attempts.

I mean if you are seeing them on the back or buttocks or on the upper arms that would send up red flags.

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Specializes in ICU, CCU,Wound Care,LTC, Hospice, MDS.
I think that the location of the bruise is more of a concern vs. a bruise in general. I mean with elderly that are Coumadin they bruise easily not to mention the bruises from venipunctures! I have patients who have them on their arms and hands from all the blood draw attempts.

I mean if you are seeing them on the back or buttocks or on the upper arms that would send up red flags.

_______________________________________________

I am the Wound Nurse in my facility and do weekly head to toe assessments on everyone. It's the bruises that match four fingers and a thumb on an arm that I report to the DON and a follow up is done.

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Wow how awful.

Its like you have all the time in the world to sit and write a 15 page essay..:rotfl:

Ours are one sheet front and back. We have a skin protocol for brusing , fall assesments and a head injury protocol if needed.

Why is it that the people that design these sheets think nurses have all this extra time on there hands. I hate the paper work crap of nursing !!! :chuckle

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