Incident Reports

CapeCodMermaid, RN · Jun 16, 2005

NO NO NO....ask risk management! We never say we've done an incident report. They are for internal use only so an attorney could never see one...unless we wrote we did one.

mcmike55 · Jun 17, 2005

I agree totally with CCM.

No way should you ever chart "incident report filed".

Pt records can be obtained by lawyers, internal records such as incident reports cannot, to the best of my knowledge.

If, God forbid, an incident takes place, and a lawyer is looking over a chart, that type of notation is a red flag!!! Heck, probably a red flag with neon lights around it!! :)

I'm not sure, but if reference is made to an incident report in the chart, that may make it available to legal.

Check with risk management people. What I have always done is just chart the situation that happened....doc notified, orders, etc.....and that's it.

Then make out the incident report.

Over the years, at least at my hospital, incident reports are not make you feel bad, point fingers or up for blame. Incident reports usually uncover problems with the system, and show how it broke down and let this happen.

Check with your bosses, and risk management!

Mike

Bird2 · Jun 17, 2005

I have never heard of a facility keeping the incident reports in the chart. We keep them in a binder and locked in an office. We NEVER chart the word incident. It sounds as though someone misunderstood the process??

lewwilann · Jun 17, 2005

I agree totally with CCM.
No way should you ever chart "incident report filed".
Pt records can be obtained by lawyers, internal records such as incident reports cannot, to the best of my knowledge.
If, God forbid, an incident takes place, and a lawyer is looking over a chart, that type of notation is a red flag!!! Heck, probably a red flag with neon lights around it!! :)
I'm not sure, but if reference is made to an incident report in the chart, that may make it available to legal.
Check with risk management people. What I have always done is just chart the situation that happened....doc notified, orders, etc.....and that's it.
Then make out the incident report.
Over the years, at least at my hospital, incident reports are not make you feel bad, point fingers or up for blame. Incident reports usually uncover problems with the system, and show how it broke down and let this happen.
Check with your bosses, and risk management!
Mike

Exactly! but this is a corporate form :uhoh3: .....large nursing home chain. This is no misunderstanding...the directions on the form tell us to do it...Maybe someone else works for this company??

Nother question...so even if this is policy now...am I more liable?

MS._Jen_RN, ASN, RN · Jun 17, 2005

:yeahthat:

Same as above here in MI.

~Jen

txspadequeenRN, BSN, RN · Jun 17, 2005

no no no

there should never be any mention of ir in the charts anywhere!!!!!! you are making it easy for a legal team to slice and dice you. oh this just gives me cramps.

my company now has a new form that we are to fill out for incidents. when we are done, we are to place it in the chart in the nurses notes sections. then make a note...incident report filled out..date it and sign it. this report and notation would be our nurses note. since they will be out of order...that is why we will indicate that we did an incident report.
goes against everything i was taught...any one else doing this?

CoffeeRTC, BSN, RN · Jun 17, 2005

Okay....I think what I would do is fill out the incident report per policy...place it in the chart....then make a note as you would have before without writing the words "incident report"....

Bird2 · Jun 17, 2005

Okay....I think what I would do is fill out the incident report per policy...place it in the chart....then make a note as you would have before without writing the words "incident report"....

I agree. Follow the policy but cover your own butt.

lewwilann · Jun 17, 2005

Michelle...I like your idea.

Does anyone else work for this co? (Starts with an E)??

What are you doing? PM me if you have any idea?