How to improve my charting and filling out incident/fall reports?

deleern · Jan 2, 2010

Read other nurses charting.

for a Fall ask yourself questions... was it observed/unobserved. were any alarms sounding. position in the room what equipment is involved, WC, bed, .... was there any hazards, water on the floor. did he trip over his slippers.

then look at the resident . injuries should be noted. or lack of. VS before you get them up and then after they are in the chair/bed. Make sure you talk to the resident and chart what they say. Then contact family chart what they said. (go by facility policy) then chart what you are going to do. VS and neuros Q15 min. then q1hr then q2hr the q4 hr for 24 hours. Then if this is a repeat fall then I would put on a Chair alarm/ bed alarm.

fill out the incident report. (again follow your facility policy) make sure to report to the next shift.

hope this helps.

Nascar nurse, ASN, RN · Jan 2, 2010

An incident report should "paint a picture" of what you observed at the scene.

Include what position the resident was found in, was the floor dry, was the call light on, if alarms are assigned - were they sounding, did the resident have shoes on, was there any equipment involved and did it function properly. Be specific when describing resident injuries and measure wounds. If the resident makes any comments about the incident, use exact quotes to relay their input (ie: "I was trying to get up and go to the bathroom and forgot to put my call light on").

Make sure to include any interventions that are put in place to prevent the incident from happening again.

tango.in.paris · Jan 2, 2010

Is there a book/site of examples of how to improve on writing out notes and incident reports? Or advice. I'm not as good as I want to be in this department and would like to improve. Any help or advice is much appreciated.

Hi CrystalClear75,

As I'm sure you already know, the constant with all progress notes and incident reports is only to write what you know/what you've seen/what you've done/what you've experienced first hand. You don't need second hand words/fancy words/rambling. Just be legible, professional, accurate and as concise as possible while telling the complete story, and then you can't go wrong .... after all, we don't have to make anything up! PS I was also taught to be chronological within a lengthy note.

Finallydidit · Jan 10, 2010

When charting I try to paint a picture, so anyone looking can all but see what condition the Res. is in at that time.

If I am charting for MC... I include, what theropy the res. recieves, OT for gait/balance, transfer training etc, ST for swallowing diff, I chart if they recieve coumidan, or if they have DM with s/s insulins. If they are feeders, or only require tray set up, continent, I/O, ADL assist if so how many person.

If it is a wkly skin assessment charting, I do a head to toe assessment, and chart skin conditon, lung and bowel sounds, pedal pulses, edema, contractures, open wounds old or new, and the tx given, dressings when last changed etc.

Alert charting I do at end of shift, and chart actions of Res all shift, include reason for being on alert, abx, fall, skin tear etc. Any reaction to tx of such, side effects of abt, PRN pain meds given for fall, bleeding of skin tear etc.

If charting for an incident report, I always make sure that I chart the MD notified by name, and the family member notified by name and relationship. If I contacted the DON I chart that as well.

PammyRN,CEN · Jan 21, 2010

Fall investigation tool.

dayspring fall questionaire.pdf