Incident Reports

[Yayamaya, RN]

I am a bit confused about incident reports and would appreciate some clarification.

1. Does the nurse indicate in the patient chart that 'an incident report' has been filed?

2. An incident report is never to be kept in a patient chart right?

3. Does the nurse need to have the patient's signature on an incident report?

Thanks so much

[cook1043]

No, you should not document that an incident report was completed, and a copy does not go into the patient's chart, and the patient does not sign the incident report.

[Whispera, MSN, RN]

I agree with cook1043

[CathyLew]

you should ask your supervisor, or a more experienced nurse about what to put in the incident report also... I agree with those above, no, no and no.

doccument in your notes very well about the incident, but not the report. Don't try to hide anything. if the incident is the patient was found on the floor, just doccument how your found the patient, how the pt was transported back to bed. If there were any injuries. who you contacted. the falls prevention things in place at the time of the fall, and any additional falls prevention things put in place after the fall. pts VS and pain level. LOC, etc. also make sure the care plan is updated. these are things that the person following up with the incident will look for.

[mcknis]

agree with the above! no, no, and finally, no!!!!!!!!!!

[kids]

I am a bit confused about incident reports and would appreciate some clarification.

1. Does the nurse indicate in the patient chart that 'an incident report' has been filed?

2. An incident report is never to be kept in a patient chart right?

3. Does the nurse need to have the patient's signature on an incident report?

Thanks so much

1 & 2 is going to depend on the facility. I did some agency shifts at a couple of facilities (nation-wide chain) and the corporate policy was to put a copy of the incident report in the chart.

3) I hev never even seen a space for it.

[rainyann]

I work in Nursing Quality and the answer to all 3 is NO

[Ginger's Mom, MSN, RN]

The purpose of an incident report is two fold, one is for risk management to advise them of a potential legal matter and secondly for quality to see if there is a trend with this issue. I agree all 3 are NOs.

[GlblRN]

I am a male nurse and as a professional I understand the importance of incident reports. However, I am stunned to find how nurses file such reports on each other far more than physicians. I admire how they help and protect each other, while nurses seem to relish in joy at the demise of their colleagues. While not wishing to engage in stereotypes, I wonder if there is a link to gender and how gender groups treat each other since MD's have traditionally been male and nurses predominantly female.

[TechnoDanceNurse]

I found this in my nursing text:

"The nurse should never note in the patient's medical record that an incident report has been completed and filed. This may alter the protection from discovery normally provided the document in some states. The jury also will be made aware that an incident report has been filed because they have access to nurses' notes submitted in evidence during the trial."

(Cherry, Barbara. Contemporary Nursing: Issues, Treands and Management, 4th Edition. Mosby, 102007. p. 171).

It seems unethical to me that there is an active effort to "protect the discovery" of an incident report. I suspect that the words "incident report" upsets juries, and that's why there's an active effort to omit them from the chart.

I figure if I do my job competently, then that's the best protection I have - not cunningly worded bureaucratic paperwork. I'm sure lawyers and business managers see it otherwise. That's why I'm glad to be a working person, and not behind a desk. They can keep the money and power, I prefer dealing with truth and reality. There's something spiritually gratifying about it - honest and pure.