charting"incident report filled" in nurse's notes

NICURN04 · Jun 4, 2008

oh, I forgot to add the fact that she was on 21% of FiO2, BNC before she went to surgery to have a VP shunt place.

CritterLover, BSN, RN · Jun 4, 2008

you are not supposed to mention incident reports in the chart.

doing so makes them fair game for attorneys. otherwise, the incident report is an internal document, for use by risk management/qi/qa.

Simplepleasures · Jun 4, 2008

Most will say yes, not to use those "flag words", BUT why not , why do we do our employers bidding by trying to hide what the state or other regulating entities, should know about and have free access to? It's NOT just hiding things from lawyers.

IF it were your baby in question, would you not want to have access to all the records and know if there was an incident report filed? I think the culture of nursing needs to change in a way that we as nurses feel safe telling the truth and not getting retaliated against by the employer.

FlyingScot, RN · Jun 4, 2008

Maybe I'm missing something here but what you described as occurring is not an "un-planned extubation" which I read to mean the tube came out accidentally. The RT and you purposely extubated the baby to change the ETT size. So filling out an incident report shouldn't even be necessary. Are your RT's normally allowed to make these kind of decisions without physician or NP input (in some units they are). If not then this is beginning to sound fishy to me like the RT is trying to cover his/her butt for going out of their scope of practice in your hospital and when you charted "unplanned extubation" it wasn't really factual. In any case no you shouldn't chart the presence of an incident report regardless of how little respect you have for your hospital. These really are meant to be internal monitors of systems to allow problems to be identified and fixed. Not to mention if a lawyer gets hold of it the hospital isn't going to be the only one squirming.

aeauooo · Jun 4, 2008

No, NEVER chart that an incident report was filed. Your charting should reflect the care that was given and be the only discoverable document.

As CritterLover wrote, it is an internal document. If you chart that an incident report was filed, it becomes discoverable.

"What Not to Do:

"The incident report is generally considered to be an administrative record of the facility, not part of the legal medical record. That is why the fact an incident report has been completed is not documented in the patient's medical record, nor a copy placed in the patient's medical record. (emphasis mine)

"The incident report is not the place for speculation, editorializing or laying blame. The investigation of the root cause of an event is best left to individuals charged with making those conclusions for the facility - the risk manager, patient safety officer or quality assurance. Likewise, the medical record completed contemporaneously with the incident report should only contain factual, objective, descriptive documentation relative to the patient's condition and response to the incident."

https://nursing.advanceweb.com/CE/TestCenter/Content.aspx?courseid=558&creditid=1&CC=78543&sid=1981

kmoonshine, RN · Jun 4, 2008

As others have mentioned, do not chart that an incident report was filed (allows access for lawyers). Incident reports are internal reports and are to examine what happened, how it happened, and how to prevent it from happening again.

I'm not a NICU nurse (so forgive me if any of this info is incorrect), but is it in the RT's scope of practice to intubate neonates? What would you have done if the baby couldn't be re-intubated? Now, THAT is a lawsuit waiting to happen. If the baby's Sp02 was WNL and CRT w/vitals were normal, the ET tube shouldn't have been touched.

Your charting should have reflected when you paged the NNP and the baby's response to treatment. The RT should have filled out the incident report - not you (unless you were filling it out to report them for practicing outside of their scope of practice). If the baby wasn't doing well, the Rapid Response Team should be called (if one is available at the hospital). As I said, I'm not a NICU nurse - but I don't think I would have allowed the RT to extubate, then reintubate the patient.

Why was it so urgent to change the ETT immediately? You wrote that the RT was securing the ETT when the NNP arrived - doesn't sound like a lot of time had passed from paging the NNP to when the NNP arrived.

aeauooo · Jun 4, 2008

This begs two questions:

1. What would you put in an incident report that you wouldn't put in your charting?

2. If you chart that an incident report was filed, what is it that you want to testify in court that you wouldn't put in your charting?

Whatever you want to have to say in court should be in your charting. I don't see why anyone would need or want to add anything to that - unless you're trying to finger someone else for blame, which isn't the point of an incident report in the first place. The purpose of an incident report is to prevent a similar event in the future, not a punitive report.

miko014 · Jun 4, 2008

Incident reports are not part of the medical record for a reason. They are used for internal review and process improvement. If you chart that one was filed, it automatically makes it look like someone was negligent. That's not always the case. I don't understand the whole NICU/RT situation, but that whole thing sounds fishy on the part of the RT.

If, say, you start to give a med, and then catch yourself before you give it and go, "oh, crap, that's not the right med!", you're supposed to write an incident report as a "good catch" so that it can be used to try to follow up on why that happened. If you start charting that incident reports were filed, then it will discourage people from filling them out for fear or getting in trouble. Just the words "incident report" make people uncomfortable because it sounds like a bad thing, but they are meant to be used to imporve safety and care for pts, and for us.

BittyBabyGrower, MSN, RN · Jun 4, 2008

You shouldn't chart about an incident report like the others have said. It is a document that is evaluated by risk management to see if follow up needs to be done and also to be used in the event of a lawsuit for info.

I don't get why they wanted an incident report....an unplanned extubation is when the tube falls out or is pulled out during a procedure, this was an ELECTIVE reintubation based on clinical findings.

Maybe you should talk to your manager about this.

pagandeva2000, LPN · Jun 4, 2008

I have always been told not to document that an incident report was written in nursing notes. I can see the reasoning for saying that one was written, especially if there was nothing to cover up, but I believe it is best to document the findings and responses without adding that an additional document was written elsewhere. Let the powers that be deal with the rest.

MichaelFloridaRN · Jun 4, 2008

Didn't they tell us to never write that in the nursing notes?

From what you describe, I see no big deal, and not even sure if that would an incident on a big person since it was not pulled out. Or did the neonate pull out his tube:wink2:

Now for the real thing, if my facility and their policy caused something very dumb to happen then I would write Incident Report Filled in the chart in large letters, underline it and highlight it, but so far I have not found any cause worthy of doing just that.

Like someone else said, normally what would you NOT write in the chart, that matters to the patient, and is part of the report?

And remember things like the doc cursing do not matter to the patient, neither does the fact that you had to call the pharmacy 29 times to get a med, unless the delay hurt the patient. Get my drift?