Confused about incident report

[ladylibra018, BSN, RN]

Hi guys im doing question right now and the topic is "reporting of incident/event/irregular occurence/variance" im using kaplan. So it says that i should document the Incident report in the clients record. Then i consult my saunders it says dont put it. Now it left me confused.. all my as a nursing student it says not to put it in the record.

[heron, ASN, RN]

Does Kaplan say to document the report, specifically? The actual incident should be documented but, I've been told, not the fact that an IR was filed.

[dslrjunky]

document the incident, but without mentioning of IR in the clients chart /record

[ladylibra018, BSN, RN]

thats the questioon

[Tridoral]

Kaplan isn't telling you to document the completion of a IR in the client's record. Kaplan is telling you to document the event in a IR and in the client's record.

[RiskManager]

As the risk manager, I agree that the event should be documented in both the patient's chart and in an incident report. You do not, however, note in the patient's chart that an incident report was filed. You mention nothing about incident reports period in the patient chart. The reason for this is mentioning in the chart that an incident report was done can imperil the legal protection from discovery enjoyed by incident reports.

[nurseprnRN, BSN, RN]

The answe as given is correct-- you must always document what happens to a patient, including wrong med times. The conventional wisdom and policy is never to mention the existence of a variance report/incidence or incident report/ report of adverse occurrence or whatever they call it because if that is mentioned in the record then it is subject to legal discovery. So that is the answer to the question.

just so everybody knows, though, there isn't an attorney in the land who doesn't know that this report exists. It may still be discoverable. If the charting is correct, there shouldn't be anything different in the report them there is in the chart, anyway-- we (the legal nurse consultants who would be asked to review the chart) would look for obvious holes in the documentation. If the report invites you to speculate on the cause of the error or incident, you might consider doing that verbally to your risk manager, rather than in writing. However, if it does come to litigation and you must testify under oath in deposition or in court, they will ask you why this happened and you will have to answer.

[RiskManager]

^^^I require my people to put in the incident report any speculation or theories on the cause of the incident or how to prevent similar incidents in the future. That is one of the most useful parts in my analysis and mitigation work on incidents.

[ladylibra018, BSN, RN]

Thank you guys