Incident reports/ statments

[guest114]

Hi everyone, I have been working in LTC for almost a year now and the time has finally come where I have to write a statement regarding a fall. I did not witness the fall but was the first person there to find the resident. She tends to get up on her own and she came into the hallway looking for help to use the bathroom. She is very confused and recently fell and had to get multiple stitches in the back of Her head. As I was following her back into the room to help her, she was walking very quickly, basically running back toward her bed in the room was dark and I heard her hit the floor as I was entering the room. It appeared she hit her face on a wheelchair nearby and also cut her middle finger open on her L hand. I need to know how to write a proper statement to my employer regarding this incident. I have created a rough draft, but I am not sure if there's anything anybody else can offer to make sure it is done correctly. Thank you all in advance!

[brownbook]

You are probably waaaaaay to young for this TV reference....but when I write incident reports I think of an old TV police show where the sergeant frequently said "just the facts ma'am" when interviewing witnesses.

You have to of course give some details....but at least with incident report forms I have seen there is not a lot of room. Try to stick with the facts for that specific incident, don't bring in prior falls or that she is very confused...just the facts....I saw her in the hallway..I followed her back to her room...she got to her room before I got there and I heard her hit the floor. I saw nothing on the floor that could have caused her to trip or slip.

[guest114]

Lol thank you so much ! I found this to be very helpful. would I include something on the end like "I called for the other nurse on the unit, the patient was assessed and the supervisor & MD notified. The resident was sent to GSH ER for evaluation." ???

Also do I include any injuries I noted? For example : she hit the right side of her face and there was a laceration to her finger ... Although I didn't see it actually happen

[RNNPICU, BSN, RN]

You can state what assessment finding you found. You can't guess to mechanism of injury since you did not see it, but what you stated above sounds great

[brownbook]

I can't remember to be honest. The incident reports I have used...and thankfully it has been a while.....have a lot of "check" boxes. I am betting there is probably a check box for...was the MD notified...yes/no.....and various other "yes/no" questions.

I know many nurses think they need to, have to, write a long detailed explanation, but I think, assume, risk management just wants a simple brief explanation. Maybe (I don't mean to scare you, just trying to figure this out myself) if a lawyer is able to see the incident report, the less written down the better in regards to law suits.

What little I know, and it is very little, it "depends" on whether or not a lawyer can see an incident report.

[iluvivt, BSN, RN]

Incident reports are meant to be internal documents so problems can be identified and corrected. You should never chart such as,"An incident report was written", in your charting or they indeed may become discoverable.