Nurses Helping Nurses
allnurses Network: Central | Jobs | Books | Newsletter
allnurses: A Nursing Community for Nurses
Home General News Blogs Articles Students Region Specialty Degrees F.A.Q.
Legal Nursing /

Incident/Occurrence reports & Documentation...



Did You Know?
allnurses is the largest community for nurses on the web. We now have over 388,775 members! Join today to network with other nurses, laugh, share, and much more.

Sep 06, 2005 09:31 PM

Incident/Occurrence reports & Documentation...


I have a question about Incident/Occurrence reports and documentation...
When I was in nursing school (graduated 2000), we were told never to write 'Incident form completed' in our charting. The rationale for this I was told was that incident/occurrence forms is solely for hospital/risk management use, not for the purposes of potential/future liability. Having said that, we had an inservice where I used to work at where one of the attorneys from the legal department came in to talk to us about depostions. When this issue was asked, her response was to chart that the incident form was completed because attorneys know all about incident forms and so if any were written pertaining to an incident, the form(s) will be found out anyway.
Fast forward to today...I just finished day one of new hire hospital orientation at my new workplace. Someone from Risk Management came in to give their presentation and she reiterated what I suspect what they're still teaching in nursing school...not to write 'Incident form completed' when charting. Her rationale was the same as what I was told back in school.
To my legal nursing clinicians...what's your take on this? what would you advise?


Share

Search Tags
None
Top

 
Advertisement
Sponsored Links
 
Reply
3 Comments
No. 1
from Jolie
Old Sep 06, 2005, 10:08 PM

I believe it is inadvisable to make mention of an incident report in the patient's chart. Incident reports are intended for use by hospital personnel and the hospital's legal team. They are written up for many incidents that do not lead to lawsuits. But imagine if a patient were to request a copy of his/her records for some other puropse only to see the notation "Incident report completed." That would be an invitation for a patient to consider legal action for something that may otherwise not have raised any red flags.

Also, when a lawsuit is filed, the plaintiff's attorney will file discovery motions to obtain any and all records pertaining to the incident in question. At that time, the attorney is free to request (and receive) a copy of any incident reports. It is my way of thinking that we should let the plaintiff's attorney do his/her job and request the paperwork, rather than handing it to him or her on a silver platter by broadcasting in the patient record that an incident report exists.
Top
 
No. 2
from ShirleyM
Old Sep 06, 2005, 10:49 PM

Originally Posted by Jolie
I believe it is inadvisable to make mention of an incident report in the patient's chart. Incident reports are intended for use by hospital personnel and the hospital's legal team. They are written up for many incidents that do not lead to lawsuits. But imagine if a patient were to request a copy of his/her records for some other puropse only to see the notation "Incident report completed." That would be an invitation for a patient to consider legal action for something that may otherwise not have raised any red flags.

Also, when a lawsuit is filed, the plaintiff's attorney will file discovery motions to obtain any and all records pertaining to the incident in question. At that time, the attorney is free to request (and receive) a copy of any incident reports. It is my way of thinking that we should let the plaintiff's attorney do his/her job and request the paperwork, rather than handing it to him or her on a silver platter by broadcasting in the patient record that an incident report exists.
Thank you Jolie, I've never heard it explained it that way before, that makes total sense to me now
Top
 
No. 3
Old Sep 07, 2005, 02:29 PM

What you learned in nursing school is correct. You should never mention the incident report in the patient's chart. They are protected by QA laws and considered attorney-client privileged information - between you and the risk management department. By mentioning them in the patient's chart you make them a part of the medical record and run a higher risk of making them discoverable information.

The attorney is correct in stating that all attorneys know about these and will ask for them in discovery. Any good attorney for your side will fight to keep these from being discoverable. On rare occasion, I have seen a judge allow parts of an incident report to be given to the other side. The judge will block out the parts that he feels is protected information.
Top
 
Reply




Thread Tools


Who's Online
79 members
1,046 guests
1,125

5

Four Lehigh Valley Health Network nurses accused of...

48

lawsuit - But don't most RN's work through breaks/lunch...

0

Patient Evaluation of Retail Clinic Care

7

The hard to reach on-call doctor, and its effects on...

12

Woman charged with passing off prescription drug as...

26

Man in "Vegetative State" was conscious for 23...

2

Interesting article on ThedaCare's Collaborative Care Model

14

Possible breakthrough regarding MS

63

16th Philly area hospital to stop delivering babies: Mercy...

14

Really interesting article on Indian open hearts






Currently Reading This Page: 1 (0 members & 1 guests)

Interested in the hottest topics of the week? Subscribe to the Nurse-zine Newsletter.
Enter email address: