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.

[Patient Advocate First, RN]

If it was not documented then it was not done! If I am required to submit an incident report, DUE TO AN INCIDENT THAT INVOLVES MY PATIENT, then it will most certainly be documented that one was filled out. I am the patient advocate on the BEDside of things if NO ONE ELSE IS and its me and them against the world. The fact that "we all know reports are filed" is irrelevant if the hospital can lie or NOT provide the report if it is NOT mentioned in the chart (which is a FACT).  As a bedside nurse, knowing that they will hide and not provide all information with regard to a negative outcome just reinforces my decision to document because I will tell you, from over 20 years at the bedside, they will ALWAYS throw the nurse under the bus and it is usually lack of nursing documentation that hurts the most. If I am wrong for stating "incident report filed" then I will take the heat forever. With my experience, it is my opinion that healthcare in capitalism ENDS at the bedside , HealthBUSINESS begins at the lowest level of administration and I will always butt heads when putting profit or business before people. In addition to stressing documentation in nursing school they also taught us that we in a field of evidence based and best practice when actually it is financially driven just like the advice to not chart the incident report. Legality does not equate to morality. 

[Rose_Queen, BSN, MSN, RN]

Patient Advocate First said:

If I am required to submit an incident report, DUE TO AN INCIDENT THAT INVOLVES MY PATIENT, then it will most certainly be documented that one was filled out.

Incident reports are internal documents used to drill down on causation. They are not to be documented in the medical record; rather, the information contained within the incident report should already be in the medical record. Referring someone to something outside the medical record is not the proper procedure. Documenting that an incident report was completed opens up the possibility that outside agencies can request access to protected internal documents.