Published May 10, 2003
could someone please clarify this-- when an incident report is written up does it become a part of the patient's chart and do you chart " see incident report" in the nurses notes instead of charting the details in the nurses notes? i was always taught that the incident report was used as a tracking tool and not placed in the chart and also you did not chart the word incident report in the nurses notes--BIG RED FLAG-- but now i am seeing it charted in the nursing notes incident report filed and the incident report itself is a part of the record
I believe each institution or corporation has their own policy regarding it. Our companies policy is that it is a facility document. You do not chart that an "incident report is completed" and it does not become part of the medical record. This is usually the standard. Make sure you check the policy and procedure on your incident reports. Despite companies having this policy....many nurses have in error continue to chart erroneously and place it in a medical record.
P_RN, ADN, RN
the incident report is a heads up to risk management that "something" happened. no you do not chart that you filled one out. the phrase "incident report filed" is a big red flag to a malpractice lawyer. and on the report neither admit nor assign guilt.
also see the responses here to the similar question by niteshiftnurse.
At my facility, the incident report is filed with the current nurses notes in a seperate binder. It is NEVER put into the chart. As for the charting-we document what happened and what was done, as well as notifications. But we NEVER,NEVER chart that it was filled out.
Just FYI, the incident report can be admissable in a court of law. PRN gave some great advice.
Ditto P_RN's advice...I was always told an incident report was as much a benefit for YOU as it was for the facility you work for.Just in case the event (hopefully not) goes to court, your report and your charting are your salvation.And be sure to stick to the FACTS only, don't offer uneeded info.
In my state the incident report is protected information that is not admissable in court. If we charted any reference to an IR in nurses notes we would be looking for another job. The rational for this is that an IR is privilaged, to be used to correct methods and procedures internally. By it being privilaged, all parties involved are thought to be more honest, and detailed in what they did do or what they failed to do. This encourages new and better policies regarding patient care.
Here's an example. Say you gave a patient 2 units of insulin when they were on sliding scale and their BS was lower than the required number to receive this insulin. Big mistake. You could chart in the nurses notes "Humilin R 2 units given at 1130. Vital signs ..........FSBS 180, Doctor notified". Then at 1200 you could chart "No hyper/hypoglycemic reaction noted, FSBS 150, VS 120/80 pulse 80 ect.. patient eating lunch.." This would be accurate information. Now on your incident report you would list all the details of the mistake.
Of course this is just a theoretical example. Hope it helps.
My hospital no longer calls them "incident reports;" they are now titled "safety forms" and are referred to as "Sentinel Events." These forms do not go in the chart either; nor are they referred to in the chart.
We have supposedly switched to "blameless reporting," where all facts are stated clearly and concisely and anything that may have led to the incident is recorded there, including any department that may have added to the problem. These forms are then studyed by the Safety Committee who then try to correct what failures in the system caused the specific incidents.
The person filling out the form is not considered the "guilty" party either; which really helps to make sure the forms are filled out and all incidents are reported so problems can be corrected in a timely manner.
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