Documentation

[Nuresecc283]

We all know NOT to chart “incident report filed”

my question is what exactly DO you chart in the patients chart when an incident occurs??

[Rose_Queen, BSN, MSN, RN]

A factual statement of the details. In my world, that may be:

Final surgical count incorrect. Patient with intentional retained items as abdominal packing. Items include: 1 QuikClot pad, 5 lap pads, and AbThera wound dressing.

When the patient returns to OR:

Final surgical count incorrect. Previously intentional retained items removed: 1 QuikClot pad, 5 lap pads, and AbThera wound dressing. X-ray taken and read as negative by (radiologist) prior to patient exiting OR.

[Sour Lemon]

2 hours ago, Nuresecc283 said:

We all know NOT to chart “incident report filed”

my question is what exactly DO you chart in the patients chart when an incident occurs??

I chart exactly what occurred, and no more. For example, a covering nurse gave a wrong medication (new order and pharmacy was bypassed) to my patient while I was at lunch. Since the medication administration was already documented, I only charted my observations for any adverse effects of that medication.