Re: is this legal? Originally Posted by Not_A_Hat_Person 
At my job, we were specifically told not to write "incident report filed" because incident reports are not part of the chart.
This is common--incident reports are for the facility's use only, for tracking and quality improvement. However, there are usually other places that all the info from the incident report needs to be recorded. We have a change in mobility form, fall risk assessment, skin assessment, neuro checks, 'falling star' precautions, etc. that all have to be filled out any time there is a fall. The only info I can think of (off the top of my head) that goes on the IR and nowhere else is the staff information--where was the resident's aide at the time, where was the nurse, what else was happening.
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