Incident/Occurrence reports & Documentation...

[ShirleyM]

I have a question about Incident/Occurrence reports and documentation...

When I was in nursing school (graduated 2000), we were told never to write 'Incident form completed' in our charting. The rationale for this I was told was that incident/occurrence forms is solely for hospital/risk management use, not for the purposes of potential/future liability. Having said that, we had an inservice where I used to work at where one of the attorneys from the legal department came in to talk to us about depostions. When this issue was asked, her response was to chart that the incident form was completed because attorneys know all about incident forms and so if any were written pertaining to an incident, the form(s) will be found out anyway.

Fast forward to today...I just finished day one of new hire hospital orientation at my new workplace. Someone from Risk Management came in to give their presentation and she reiterated what I suspect what they're still teaching in nursing school...not to write 'Incident form completed' when charting. Her rationale was the same as what I was told back in school.

To my legal nursing clinicians...what's your take on this? what would you advise?

[Jolie, BSN]

I believe it is inadvisable to make mention of an incident report in the patient's chart. Incident reports are intended for use by hospital personnel and the hospital's legal team. They are written up for many incidents that do not lead to lawsuits. But imagine if a patient were to request a copy of his/her records for some other puropse only to see the notation "Incident report completed." That would be an invitation for a patient to consider legal action for something that may otherwise not have raised any red flags.

Also, when a lawsuit is filed, the plaintiff's attorney will file discovery motions to obtain any and all records pertaining to the incident in question. At that time, the attorney is free to request (and receive) a copy of any incident reports. It is my way of thinking that we should let the plaintiff's attorney do his/her job and request the paperwork, rather than handing it to him or her on a silver platter by broadcasting in the patient record that an incident report exists.

[ShirleyM]

I believe it is inadvisable to make mention of an incident report in the patient's chart. Incident reports are intended for use by hospital personnel and the hospital's legal team. They are written up for many incidents that do not lead to lawsuits. But imagine if a patient were to request a copy of his/her records for some other puropse only to see the notation "Incident report completed." That would be an invitation for a patient to consider legal action for something that may otherwise not have raised any red flags.

Also, when a lawsuit is filed, the plaintiff's attorney will file discovery motions to obtain any and all records pertaining to the incident in question. At that time, the attorney is free to request (and receive) a copy of any incident reports. It is my way of thinking that we should let the plaintiff's attorney do his/her job and request the paperwork, rather than handing it to him or her on a silver platter by broadcasting in the patient record that an incident report exists.

Thank you Jolie, I've never heard it explained it that way before, that makes total sense to me now

[fiestynurse]

What you learned in nursing school is correct. You should never mention the incident report in the patient's chart. They are protected by QA laws and considered attorney-client privileged information - between you and the risk management department. By mentioning them in the patient's chart you make them a part of the medical record and run a higher risk of making them discoverable information.

The attorney is correct in stating that all attorneys know about these and will ask for them in discovery. Any good attorney for your side will fight to keep these from being discoverable. On rare occasion, I have seen a judge allow parts of an incident report to be given to the other side. The judge will block out the parts that he feels is protected information.