Documenting Patient Falls

[BSN_Studnt]

I am confused on "You walk into patients room and find him on the floor, you assist him back to safety and turn bed alarm on, then you must record the event in?" The book says medical record and incident report but I thought you NEVER document that kind of stuff in the medical record ??

[amoLucia]

JKL - I understand what you're saying. I believe in the short, sweet & simple school of charting in nsg note. But since we're talking about falls; anytime a pt was on the floor (EVEN WHEN GUIDED DOWN) it started the chain of events re charting, incident report, phone calls, etc. Even if pt was on a 'low bed' frame and scooted off 6 inches to a mat on the floor, we had to count it as a 'fall'. Even if the pt slid off twice, only 10 min apart, the whole enchilada again.

My documentation would clarify "no injuries noted' and the critical safety measure in place. But still there would be an incident report. And the silly thing is that the 'meat' of both the IR and NN would almost be word for word.

I guess what I'm really protesting is the fact that we shouldn't be writing "incident report filed" EVEN THOUGH we all know we ARE doing one.

[K+MgSO4, BSN]

Could you explain this further please?

Sorry, may be using abbreviations that are Australian centric.

When a lawyer applies for a copy of all records pertaining to the client under the FoI (Freedom of Information Act) there is a person employed by the hospital who makes the decision what to redact from medical records, In-depth Case Review (IDCR) or Root Cause Analysis (RCA) in conjunction with the medical administrator.

[Crush]

An incident report is more of an administrative record specifically for the facility's QA/PI and risk management, not part of the legal record. It is used for a root cause analysis. The medical record should only contain the objective facts, a descriptive summary of the patient's conditionand response to the incident.

Basically, an incident reportis internal and is used to examine what happened, how it happened, and hopfully to prevent it from happening again.

At least this is what I was taught in nursing school. Unless something has changed.

[Amethya]

An incident report is more of an administrative record specifically for the facility's QA/PI and risk management, not part of the legal record. It is used for a root cause analysis. The medical record should only contain the objective facts, a descriptive summary of the patient's conditionand response to the incident.

Basically, an incident reportis internal and is used to examine what happened, how it happened, and hopfully to prevent it from happening again.

At least this is what I was taught in nursing school. Unless something has changed.

Thanks for the clarifications. I was confused on this and didn't understand why. But now I know when I actually go into nursing school.