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Incident Report Documentation

Nurses   (34,756 Views 20 Comments)
by khagerman khagerman (New Member) New Member

khagerman has 4 years experience and specializes in Med/Surg.

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You are reading page 2 of Incident Report Documentation. If you want to start from the beginning Go to First Page.

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..hi!i'm new here on website..dunno how to send a message.well,im getting anxious by this incident report..of course i have an idea about this but i never had an experience in this and besides im new graduate and i'll be having a new job in nursing home..I just want to know how to write an incident report.Could you please make me an example of incident report please:crying2:...thanks!!

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canesdukegirl has 14 years experience as a BSN, RN and specializes in Trauma Surgery, Nursing Management.

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Seeing as this post is several years old, I am guessing that the OP has it figured out by now that you should never refer to an incident report in NN. Being the daughter of a lawyer, my dad taught me some really great things regarding documentation: 1. Never write more than fact 2. Never be too wordy 3. Document as if you were testifying 4. If you didn't document it, you didn't do it.

Lynce-your employer will have a ready-made form for incident reports. Hopefully it will be computerized, and you just have to check boxes. There will be a section for comments. Remember in this instance that "less is more" as far as what you write. If risk management wants more info from you, they will ask you. Another thing to remember is to NEVER keep personal notes when an incident occurs. This is considered "discoverable" material in a lawsuit and can be held against you, even though your intentions are altruistic.

Please let us know how things go in your new job!

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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 mention the incident report in your notes. NEVER EVER EVER EVER. It bears yelling and repeating. :eek:

Document objectively. ("Patient found on floor upon entering room. States he fell upon attempting to independently ambulate to restroom and hit head on floor. Denies loss of consciousness.")

Document what you note upon assessment. ("No blood or lacerations noted. Vital signs blabbity blabbity blabbity. Pupils equal and reactive to light. Patient denies pain at this time.)

Document actions taken. ("Physician X to bedside to see patient before patient returned to bed. Patient to go for stat head CT. Physician ordered cervical collar to be placed on patient until C-spine is able to be cleared.")

Follow up if patient goes for testing. ("Patient returned from CT scan at 1300. Transferred to bed via backboard. Complains of 3/10 headache to right frontal area of head at this time. Physician in to assess. Tylenol ordered and administered as per order. Physician discontinued C-spine precautions. Cervical collar removed. Stressed to patient importance of utilizing call bell for assistance with ambulation within the room. Call bell positioned within patient reach. Patient verbalized understanding.)

Do not ever state what you THINK happened. State what you're told happened in quotation marks.

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Rexie68 has 21 years experience and specializes in Vascular Access Nurse.

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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, ever, mention "incident form" or incident report in your nurses notes. The form is for in facility use but if you mention it in your nurses notes it can then be pulled into court in the event of a lawsuit!:eek:

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I disagree with "never, never, never mention an incident report".

Always know and follow the policy of your facility.

I have worked in facilities where it was written policy to document in the progress notes that an incident report has been done and other facilities where it was written policy to place a copy of the incident report went in the chart.

This is one of theose situations where there is no 'standard' answer, you always follow the policy of the facility you work for.

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Rexie68 has 21 years experience and specializes in Vascular Access Nurse.

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Every facility I've ever worked in would has a policy that you NEVER mention incident report in nurses notes. Perhaps some you worked at don't care if it's pulled into court, but most would. I'd be seriously reprimanded and perhaps even fired if I mentioned an incident report in my notes. We just chart what happened. The incident report is an internal report and really has no bearing on the patient or their care.

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HamsterRN is a ADN, RN and specializes in Psych/CD/Medical/Emp Hlth/Staff ED.

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Incident reports are privileged quality assurance documents and are therefore non-discoverable (protected from subpoena). Confirming the existence of an incidence report does not change their status.

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Rexie68 has 21 years experience and specializes in Vascular Access Nurse.

296 Posts; 3,507 Profile Views

Incident reports are privileged quality assurance documents and are therefore non-discoverable (protected from subpoena). Confirming the existence of an incidence report does not change their status.

Untrue. Once it's mentioned in the nurses notes, it can be used in court. It's happened to my employer and that's why they'll go so far as to fire someone if they chart anything about an incident report. It's only a confidential, in-house document unless it is in the chart. Anything in the chart is fair game.

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