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by Nuresecc283 Nuresecc283 (New) New Nurse

Has 8 years experience.

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??

Edited by Nuresecc283

Rose_Queen, BSN, MSN, RN

Specializes in OR, education. Has 16 years experience.

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

Has 9 years experience.

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.