charting"incident report filled" in nurse's notes

Nurses General Nursing

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Hey everyone,

Last night an hour before shift change, my baby came back from surgery and was on a vent. Vent keep on beeping off, CXR was done, NNP looked at X-ray, X-ray showed that the ETT was in to far, so it needed to be pulled back just a bit, so our RTs in NICU pulled back just a bit and vent continue to go off. RTs examine vent and tubing and decided that the baby needed a 3.0 instead of a 2.5...so they notify NNP, but NNP was nowhere to be found, page NNP...RTs decide that it would be in the baby's best interest to go ahead to change the ETT..myself and another RN was at bedside. Anyway, ETT change, baby was fine, no harm to baby whatso ever...NNP came back when RTs were securing the new ETT, look at ETT and agree that it was the baby's best interest to change the tubing and everything went smoothly from there. 15 minute before shift change, one of the RTs comes up to me and stated that an incident report needed to be filled out because it was an "unplanned extubation"...so I did that...then went back to my charting and charted what happen. At the I wrote, "...incident reported filled" in the nurse's note. My question is, was I wrong to put "incident report filled" on the note???:confused::(

Specializes in mostly in the basement.

I don't know, maybe I just have been fairly lucky/ignorant or who knows, but if I had any serious situation regarding pt. care that needed an incident report, UNLESS I could somehow otherwise verify that it had been accepted and received by admin./risk management or whoever as written, I would absolutely make a note in the chart.

Nothing to make it stand out anymore than say, MD notified, etc.

Call me paranoid, but this is prime CYA and I don't care who says otherwise...

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Silly question ....why didn't the RT , who came at change of shift, write the incident report....I would have told this RT...if you want an incident report...feel free to write one....

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Specializes in Hospital Education Coordinator.

You probably know it was not the best thing to do or would not be asking. Risk mgmt. prefers we fill out the report separately. You could be getting yourself into trouble with them. Not only that, if the case went to court your actions before and after the incident would be highly scrutinized. The medical record should tell the story simply by stating the facts and not pointing out "fault".

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Specializes in neuro, ICU/CCU, tropical medicine.

There are plenty of articles in nursing journals on this very subject. I challenge anyone to find an article in a peer-reviewed nursing journal that supports noting an incident report in a patient's chart.

Good luck.

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Specializes in Cardiac, ER.

I was taught never to mention an incident report in my chart as it then becomes part of the pt's perment record if someone should ask to see it. Incident reports are intended for in house record keeping only.

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Specializes in ER, ICU, Infusion, peds, informatics.
i don't know, maybe i just have been fairly lucky/ignorant or who knows, but if i had any serious situation regarding pt. care that needed an incident report, unless i could somehow otherwise verify that it had been accepted and received by admin./risk management or whoever as written, i would absolutely make a note in the chart.

nothing to make it stand out anymore than say, md notified, etc.

call me paranoid, but this is prime cya and i don't care who says otherwise...

you might want to reconsider.

risk management tends to get very irritable when incident reports are mentioned in the medical record. i've seen nurses get fired for it (not the first time, but for persistently mentioning incident reports in the chart, despite being counseled otherwise).

if you are concerned that incident reports are "disappearing" and not making it to risk management, you can always leave them a voicemail letting them know that you filled one out and who you gave it to. or, you could follow up with them later in the week to be sure they got it.

and really, filing an incident report doesn't really do anything to cover you in the case of a lawsuit. plain, objective, factual charting does that. if anything, mentioning an incident report acts as a big, huge, neon sign for lawyers that says "mistake."

the op's story is a case in point. the situation, as presented, doesn't really scream "mistake." knowing that an incident report was filed could make someone scrutinize the situation that much closer, looking for a mistake.

eta: it is a much bigger flag than "md notified." we notify physicians all the time about things that are not mistakes -- changes in patient condition, for example.

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Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.
This begs two questions:

1. What would you put in an incident report that you wouldn't put in your charting?

2. If you chart that an incident report was filed, what is it that you want to testify in court that you wouldn't put in your charting?

Whatever you want to have to say in court should be in your charting. I don't see why anyone would need or want to add anything to that - unless you're trying to finger someone else for blame, which isn't the point of an incident report in the first place. The purpose of an incident report is to prevent a similar event in the future, not a punitive report.

I was going to say something similar. You have to chart the events in the nurses notes as they happened.

The incident report is mainly to let everyone know of the event so that everyone is kept in the loop, that an event of some sort happened, and if there's a preventative measure it can be takens.

Saying "incident report filed" while not inherently wrong, really isn't necessary is it? It's just been standard practice not to say it, but lawyers are not stupid, they know all about incident reports.

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Specializes in ER, ICU, Infusion, peds, informatics.
i was going to say something similar. you have to chart the events in the nurses notes as they happened.

the incident report is mainly to let everyone know of the event so that everyone is kept in the loop, that an event of some sort happened, and if there's a preventative measure it can be takens.

saying "incident report filed" while not inherently wrong, really isn't necessary is it? it's just been standard practice not to say it, but lawyers are not stupid, they know all about incident reports.

of course lawyers know about incident reports. but, if it isn't mentioned in the chart, then they can't get a hold of it.

and i, for one, am much more frank in an incident report about my assessment of the situations. for example, lets say a patient misses an antibiotic on a previous shift because pharmacy didn't send it. lets say the previous shift didn't call for it, but did note that the antibiotic wans't given because it wasn't there. lets also say that the previous shift didn't write the incident report, so i need to. in the chart, i will probably write something like "called pharmacy and requested vanc dose." however, in the incident report i would be more likely to mention that the previous shift didn't do anything to try to get the missing dose.

not the best example in the world, but all i can come up with right now.

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Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.
Of course lawyers know about incident reports. But, if it isn't mentioned in the chart, then they can't get a hold of it.

I almost edited that in but wasn't sure if that was true or not. I have heard that before. Thanks.

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Specializes in NICU.
in the chart, i will probably write something like "called pharmacy and requested vanc dose." however, in the incident report i would be more likely to mention that the previous shift didn't do anything to try to get the missing dose.

i agree. we have a state-required screening test that has to be performed prior to starting tpn, but preferably after the first 24h of life. twice now i've left in the am having told the day person that it hadn't been done yet because baby wasn't 24ho, so if they started tpn it needed to be done, and when i got back tpn was up but no pku. in my narrative i just chart "pku done", but in the mers i'm required to fill out i actually say "oncoming rn notified at 0700 pku not done, tpn hung at 1800, pku not done. charge nurse notified, pku done." no names, though.

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Specializes in mostly in the basement.

don't want to get argumentative here so i'll be brief:

you might want to reconsider.

risk management tends to get very irritable when incident reports are mentioned in the medical record. i've seen nurses get fired for it (not the first time, but for persistently mentioning incident reports in the chart, despite being counseled otherwise).

not really a concern, personally. though agreed you'd be dumb to a) do it again and b) imo, work somewhere that worked that way

if you are concerned that incident reports are "disappearing" and not making it to risk management, you can always leave them a voicemail letting them know that you filled one out and who you gave it to. or, you could follow up with them later in the week to be sure they got it.

i think that's what i alluded to. if procedure was in place where i get a copy signed by whomever at initial receipt then great. i haven't seen that in place anywhere yet. i only know about the big 'black hole'

and really, filing an incident report doesn't really do anything to cover you in the case of a lawsuit. plain, objective, factual charting does that. if anything, mentioning an incident report acts as a big, huge, neon sign for lawyers that says "mistake."

well, yeah, that's when i would be filing a report when a big mistake has happened. i have insurance, i chart well and frankly, i stand behind my work.

what i would be concerned with is a situation(and really i think this whole concept depends on your practice environment and the kind of facility you find yourself lucky or unlucky enough to find yourself in at any given time)where some at risk policy/procedure/situation has been reported before and has not been corrected and if by chance you should be in that same situation there is some chance that the 'entity' could deny any previous knowledge of said prior potential unsafe condition and well, really, there's no record of this in any other chart before, right? "we didn't know about it."

the op's story is a case in point. the situation, as presented, doesn't really scream "mistake." knowing that an incident report was filed could make someone scrutinize the situation that much closer, looking for a mistake.

i don't think op's story needed a report but not my call..

eta: it is a much bigger flag than "md notified." we notify physicians all the time about things that are not mistakes -- changes in patient condition, for example.

anyway, like a said, call me paranoid. i can only speak to what i know and have seen. to each his own...

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Specializes in mostly in the basement.

The incident report is mainly to let everyone know of the event so that everyone is kept in the loop, that an event of some sort happened, and if there's a preventative measure it can be takens.

.

And all i'm really saying is that is the absolute correct reason for the reports and when the process works that's fantastic.

If it doesn't or no 'reports' can be found to show a preventative measure was needed then what?

Ok, I am paranoid, but luckily I only gotta worry about my own license :)

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