incident report vs medical record

[tttiiimmmyyy]

Hi everyone, I am very confused about incident report and medical record

for example: when you waling in the pt room and you found that pt was on flow with head injury, and bleeding.

so on incident report you have to report that pt on the flow with head injury?? but for the medical record just report "pt found on flow"??

[JBudd, MSN]

Put what happened to the pt in the medical record, it is his/her health record.

Incident reports should not be mentioned in the pt chart, if you do their atty can subpeona it. The incident report is meant to be an official communication between you and the hospital atty, which is privileged information. They are also used to track falls and causes, enough reports about a problem can lead to a dangerous situation being fixed. IRs should have all the details, especially those that aren't relevant to the pt's condition, but things that may have caused a fall (sitter had been ordered and staffing office notified of need, none were available, etc.) Pt chart would only say "pt had been instructed to call for assist in getting, call bell was within reach, siderails up", as well as "pt found on floor with abrasion/laceration/bruise on forehead"

[Meriwhen, ASN, BSN, MSN, RN]

Medical record is just that: a record of the patient's medical treatment while in hospital.

Incident reports are an internal tool used to document issues/problems/concerns/causes with that medical care in order to troubleshoot and improve for the future. Incident reports are NOT part of a medical record.

Take your patient fall.

The medical record is going to summarize the facts of what happened and the medical treatment rendered. "Patient found on floor of the room bleeding from a 2cm laceration to their left temple. Patient stated they got dizzy and fell. Patient assisted to bed. Orthostatic vital signs were taken and a 20 point drop was noticed. Dr. X notified who ordered 1 L NS to be administered, etc..."

Medical record has the facts & the treatment. There is no musing about what could have caused it, no finger-pointing or assigning blame, no troubleshooting other than documenting what interventions you did (e.g., educated patient, used bed alarm, etc.). Medical record is "this is the subjective and objective data, and this is how we treated the patient."

Incident report has all of that, PLUS it looks at what could have contributed to it and what could be fixed. In addition to all the of the above, the incident report would include:

• What medications the patient was on (medication list)
  
• Who was involved (Nurses Y and Z was caring for the patient at the time)
  
• Lapses--accidental or intentional--in care (Nurse Y didn't check the BP before giving that AM Norvasc)
  
• Possible contributing factors (3 antihypertensives PLUS Zyrexa? Why didn't patient call for help if he felt dizzy? Did someone even educate the patient to do this?)
  
• How it could have been corrected (move patient closer to nurses' station to keep a better eye out, have MD review meds to see if he really needs 3 HTN meds)
  

And so on.

The incident report is used internally to see what went wrong and how things could be improved. Perhaps a policy is needed where a patient on multiple HTN meds or on specific combos of meds need more frequent VS monitoring and an automatic fall protocol...perhaps nurse Y is still a little green--or so far removed from being green--that she needs a reminder about checking BPs...

Hope this helps explain it better.