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???
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 think this varies from state to state. i know a few years ago this issue was "up in the air" in medmal/neg field. it would be interesting to know for certain. it is usually requested in discovery, as it is considered preparation for litigation. there were issues re internal risk management vs. a patient's medical record.
NEVER DOCUMENT AN INCIDENT REPORT IN YOUR CHARTING! on a side note, doesn't sound like an incident occurred to me. if RT felt differently, they have hands, let them write it up.
I have insurance, I chart well and frankly, I stand behind my work.
Good! I recommend you take a look at the advice on incident reports from your insurance company - this is from the NSO website:
"Record clinical observations in the chart, not in the incident report, and make no mention of the incident report in the patient record. The report is a risk management or administrative document and not part of the patient’s record. If there’s a reference to it in the chart of a patient who files a claim, however, his lawyers may argue that the report is part of the medical record and should be turned over to the legal team."
Again, I repeat my challenge to find an article in a peer-reviewed nursing journal that supports mentioning an incident report in the patient's record.
Everything I have seen in the nursing literature strongly advises against mentioning an incident report in the patient's medical record.
Good! I recommend you take a look at the advice on incident reports from your insurance company - this is from the NSO website:
"Record clinical observations in the chart, not in the incident report, and make no mention of the incident report in the patient record. The report is a risk management or administrative document and not part of the patient’s record. If there’s a reference to it in the chart of a patient who files a claim, however, his lawyers may argue that the report is part of the medical record and should be turned over to the legal team."
Again, I repeat my challenge to find an article in a peer-reviewed nursing journal that supports mentioning an incident report in the patient's record.
Everything I have seen in the nursing literature strongly advises against mentioning an incident report in the patient's medical record.
OMG!!
You have certainly made your opinion known and very obviously feel quite strongly about it. As we read again. And again. Oh yeah, and I think again again....
This is the post from OP I responded to:
" At the I wrote, "...incident reported filled" in the note. My question is, was I wrong to put "incident report filled" on the note??? "
You are welcome to continue reiterating how terribly wrong you feel my own answer and opinion to the question is, but guess what, I think OP can get the gist of what a forum of nurses think---including if it is only very few who disagree--and make the right and majority call all by herself!
Bless you for your concern for my daring and dangerous ways--oh that's right, which include never having filed an incident report. And good luck w/that challenge--a noble call has gone out:
ETA Also, I have a sneaky feeling that if I ever DO have to file an incident report in my facilty, I would actually WANT the info I'm providing as part of a discoverable record if you get my drift. I'll work out the kinks w/my carrier but hey, these posts can stand as record of my pre-notice of potential future wrongdoing......
I'm creating a signature for the first time--hold on a sec--I don't know how yet...
I'm confused as to why you would write the incident report here and not the RT. I also don't understand why an inceident report was even needed here. One question I did have was if the RT was practicing outside of their scope here. Just curious.
The others are right in that you don't chart about it in nursing notes. You will now know better for next time.
Specializes in Community Health, Med-Surg, Home Health.
With so many system problems going on in hospitals, I would not want to alert any red flags to myself when I am trying to do my job even with things that can happen out of my personal control. I would follow the policy of the hospital and not mention the incident report but the facts, my actions and who was contacted...but that is just me.
not the best example in the world, but all i can come up with right now.
some years ago, i was working on a post-op ortho-surgical floor. i took report on a pt. who had just had a knee replacement and who also had an artificial heart valve.
i took report at 7:00 - 7:30 pm.
by the time i got settled down and checked on all my patients; it was around 8:00-8:30 pm.
while checking the mar and the order sheet, i noticed that my knee replacement patient had not received her ordered dose of coumadin. it was supposed to have been given by the previous shift (at 5 pm).
just to make sure, i asked the patient if anyone had walked in within the past 2-3 hours and given her a pill to swallow. pt. said "no". i also double checked with pharmacy - pharmacy admitted that according to their records, they'd never sent up any coumadin for said patient.
i had pharmacy send me the dose and i gave it to the pt. following this, i filed an incident report - detailing only what i knew as fact [namely that the coumadin was given about 3 hours late]. the following morning, i hung around a little late after my shift and personally reported the incident to the surgeon when he made rounds. he was obviously upset but thanked me for notifying him. before i left the floor, i handed the incident report to my manager (we didn't have a charge nurse on nights) - who assured me that everything i'd done was per protocol. when i got home, i double checked with my "rn policy manual" just to be sure...
the idea of an "incident report" isn't to find a 'scapegoat' . incident reports exist to fulfill the "feedback" role. to identify and resolve "systemic problems". as loathsome as they seem, quality feedback is important - if it weren't there, some of the stuff we constantly gripe about would never change*
cheers,
*: now... it's a different story all together that management responds to all your complaints/incident reports... but that's the subject of a different thread!
You have certainly made your opinion known and very obviously feel quite strongly about it.
The difference is that my "opinion" isn't based on what I think the correct action is, it's based on the nursing literature and advice from professional sources.
Unrelated:
I dislike the nurses who wield incident reports like a sword of righteousness - as if incident reports were punitive. I've known a few in my career - the ones who you hear say "That's an incident report!" several times per shift.
I think most managers worth their salt recognize the value of those types of 'reports.' I can't recall a single time when another nurse has threatened to fill out an incident report over something trivial that I did or didn't do that I have ever heard another word about it.
the difference is that my "opinion" isn't based on what i think the correct action is, it's based on the nursing literature and advice from professional sources.
quote]
amen. we can argue over the presidental race, crocs ~vs~ nursemates, which shift works the hardest, etc., etc.,:argue:
..but not over documented and researched standard nursing practice. i'd really be leery of working with a nurse whose practice was determined soley by "this is what feels right to me personally..":no:
3 pages of this. Hmmmm. The OR (occurrence report) is filled out by the discoverer because until then it wasn't a "problem to anyone", then you use the minimum number of words to get the idea across to the hospital poobahs.
eg: Entered room, patient on floor, blood noted from patient's rt nares. Patient stated she slipped when she reached for a tissue when she noticed nosebleed started. Patient denied any injury. Dr XXX notified of event. Order for facial x ray (or whatever junk he wanted) received.
Don't say she fell. Don't say she had a nosebleed (let the patient say it). Don't say she was uninjured let the patient say it. DO say you notified the doc and orders carried out.
It's an occurrence, it's NOT penalty. It's only a report-like a book report.
mscsrjhm
646 Posts
i think this varies from state to state. i know a few years ago this issue was "up in the air" in medmal/neg field. it would be interesting to know for certain. it is usually requested in discovery, as it is considered preparation for litigation. there were issues re internal risk management vs. a patient's medical record.
anyone know?