Incident Report Documentation

[khagerman]

I am going to graduate from ADN program in May '07. My question is to other nurses already working on the floors, how does your hospital policy cover incident reports? Do you chart the actual incident in the nursing notes, with no mention of the incident report being filed - or do you only file the incident report? We are going to have a lawyer speak to our class about this and I am wondering what is the PROPER way to proceed with this. The institution where I am doing clinicals at does not chart any of the actual incident in the nursing notes, but eludes to the patient's well-being after incident. Our instructor did some research and found you should note the incident but not about the incident report being filed as this would make it possible for it to be subpoened in a legal proceeding. How do your institutions handle this?

[nurseofalltrades]

At our facility we chart about the incident in the nurse's notes. We don't mention a report being filed, but list all info regarding incident.It is a CYA thing I think. since the notes are legal documents, I want it in writing what happened and what I did about it.Thats just our way of doing things....dont know if its the right way! :)

[ShaunES]

Fill out an incident report form, and then make a reference to it in the notes.

Something like "Incident form for handed to NUM" or something similar would be how I would do it.

[nursemary9, BSN, RN]

Hi

We make out an Incident report; Then we write a note regarding the incident with NO mention of writing the report.

For instance, if a pt. falls; we would write a note about the fall, what was going on during the fall & what you did for the pt. including which Physician you notified & what type of orders there were. In addition, in our computer program, we have an order set for falls that must be initiated. Then we write an incident report & that goes to our Manager who sends it along to Risk Management.

[rnanm]

in our medical center we document what our findings that relate to patient safety. for instance, when i went to lunch one of my cva patients found a way to get out of the bed on her own. she was found sitting on the floor next to the bed with no apparent injuries, but upset as you can imagine. after assessing the patient and notifying the doctor i documented exactly what my relief nurse said she found, and the patient status etc. no mention of a variance or fall report was noted. this has been standard practice in most of the hospitals i work in. i did file a fall report fully detailed and took additional measures to assure patient safety.

hope this helps.

[neneRN, BSN, RN]

Fill out an incident report form, and then make a reference to it in the notes.

Something like "Incident form for handed to NUM" or something similar would be how I would do it.

NEVER supposed to document in pt's chart that an incident report was completed...I would ask your instructor about this.

I document what happened (only what actually witnessed/how pt was found), pertinent assessment findings (including VS), interventions done, and pt response to interventions in the notes.

[Ann RN]

Fill out an incident report form, and then make a reference to it in the notes.

Something like "Incident form for handed to NUM" or something similar would be how I would do it.

NEVER, NEVER, NEVER mention that an incident report was filled out in your nursing notes! That leaves it wide open for that incident report to be subpenoed in a court case.

[TazziRN, RN]

Nononononono.........NEVER reference an incident report in the pt's notes......if something legal comes of it the incident report can then be called for in court. You document the incident itself.

Example: I posted the other day about an IV the clotted off on my pt because my teammated goofed. In the pt's notes I wrote something like "IV found to be non-patent with blood in tubing, unable to aspirate. IV restarted with 22g on (site)." Nothing about how the line clotted and that I raked her over the coals for it.

[Dorito, ASN, RN]

NEVER, NEVER, NEVER mention that an incident report was filled out in your nursing notes! That leaves it wide open for that incident report to be subpenoed in a court case.

I totally agree. Stick to the facts in the chart documentation (avoid opinions) and NEVER document that a report has been filed. I thought this was standard teaching. I'm surprised that the op's nursing instructor had to research the topic.

[IrishIzCPNP, MSN, RN, APRN, NP]

Still a student but...

Where I go to school (and used to work)...incident reports are not mentioned ANYWHERE in the chart. The incident report cannot be brought in as evidence unless it's noted in the chart. So no note...no incident report. I know to me it sounds kind of crappy because it seems to protect the hospital and could cause "harm" to the pt if there is a suit...but policy is policy. This policy may cover my butt sometime.

[BittyBabyGrower, MSN, RN]

No, never mention it! That is a big red flag to a lawyer that may look at the chart! The incident report is to cover your butt...we had a page of nurses notes disappear/get lost with a really bad infiltrate and when it went to court, our lawyers were able to pull that incident report as proof that we followed the correct pathways.

[nursenikki928]

Your incident report is considered an internal investigation document. You should never document in your nurses notes that an incident report was completed. If you do, your report may be used in court. They are only to be used internally to investigate the incident. The incident its self should always be charted in the notes. Chart only the facts that you observe, and your assessment of the patient.