Incident Reports

[crb613, BSN, RN]

I know these are never to be charted in a pt chart. So how do you prove you followed policy, and that you did an incident report should one be necessary. Things get lost, and if it wasn't charted it wasn't done. I know the reasons admin does not want them mentioned in a pt chart.....so how do you cya if you can't document it? Just a little discussion we are having at work....your thoughts?

[Double-Helix, BSN, RN]

Incident reports should be sent to the department head or your facility's risk management office. They should keep them on file. If you want to CYA, personally call or send an email to your manager stating that it was completed.

Medical records are legal documents and, in the event of an investigation, any form that is mentioned in the MR becomes legally seizable. Incident reports are internal, facility records that should not be part of an investigation.

[Esme12, ASN, BSN, RN]

YOu document the events. NOT the filing of the incident report. Incident reports are for internal investigations/review only. If entered in the patient record theyare admissable in court.

EXAMPLE: "Patient found on floor with 1cm laceration to R temporal area. Patient denis any LOC. PERRLA, moves all extremities well hand grasps equal. Patient denies pain. Patient returned to be with 3 assist and denies complaints. Md and house supervisor notified as per P&P....orders noted and recieved. Patient to CT accompanied w aid." Blah...blah...blah...

and then fill out the occurance report as directed by your supervisor...OK? Is that what you wnated to know? :)

[canesdukegirl, BSN, RN]

Incident reports should be sent to the department head or your facility's risk management office. They should keep them on file. If you want to CYA, personally call or send an email to your manager stating that it was completed.

Medical records are legal documents and, in the event of an investigation, any form that is mentioned in the MR becomes legally seizable. Incident reports are internal, facility records that should not be part of an investigation.

VERY sound advice.

[crb613, BSN, RN]

YOu document the events. NOT the filing of the incident report. Incident reports are for internal investigations/review only. If entered in the patient record theyare admissable in court.

EXAMPLE: "Patient found on floor with 1cm laceration to R temporal area. Patient denis any LOC. PERRLA, moves all extremities well hand grasps equal. Patient denies pain. Patient returned to be with 3 assist and denies complaints. Md and house supervisor notified as per P&P....orders noted and recieved. Patient to CT accompanied w aid." Blah...blah...blah...

and then fill out the occurance report as directed by your supervisor...OK? Is that what you wnated to know? :)

No, but thanks for taking the time to reply....more along the lines of Ashley PICU RN's advice.

[I<3H2O, BSN, RN]

An incident report is more to help figure things out, why things went wrong and how we can fix them so they don't happen again.

In the chart, you just need what happened and what you did to rectify it.

[imintrouble, BSN, RN]

As I am an old suspicious soul, I have often thought the incident report could deflect reponsibility off the facility, and onto the one filling out the report.

In short, ammunition. JMO.