Narrative Incident Report

Jensmom7, BSN, RN · Aug 31, 2015

Mr. RD, a 72-year-old female, resident of Terrace Lodge was found lying on the floor in her room, with a puddle of fluid beside her bed at around 1430 while doing hourly checks to the resident.
He sustained a visible contusion on his forehead and skin tear on his right elbow. Vital signs were taken and assessed level of consciousness. The puddle of fluid was immediately wiped off the floor and continued assessing the resident. Checked for his leg rotation and there is no sign of hip, pelvic or spinal pain. However, there is tenderness noted on his right leg due to the fall.
The nursing supervisor was notified after the incident and resident was assisted to get back to bed. Bed brakes are on and call bell is within reach. Upper rails of the bed were raised to ensure safety. Will continue to monitor the patient with neurologic and vital signs check every hour for the first four hours after the incident. -----------------------------------------------------migueros,RN

You should also indicate if the attending MD was notified, and if any tests or x-rays were ordered.

See how showing what you've done already opens up conversation? I know you didn't get the responses you were looking for initially, but I'm glad you didn't just take your ball and go home.

There are a lot of seasoned nurses in here. Most of us don't mind having our brains picked, and offering suggestions and observations, but we already finished our homework (sometimes many, many moons ago). Meet us halfway and things will be fine.

migueros · Aug 31, 2015

First of all, i would like to say thank you for evaluating my work. Second, i am new so i just followed how people ask or post. im not aware of how things should start here and i wasnt angry or anything but i got confused how people replied and there is only a few, including you, that i appreciate for telling me how it should be done here. and once again thank you for that.

migueros · Aug 31, 2015

my question now is, in a simple incident report, a narrative type of incident report, shall i include the tests done and notifying the physician too? is my writing clear, concise and organized? thank you.

migueros · Aug 31, 2015

firstly, thank you for the feedback and taking the time to look at my work. like what ive said to jensmom7, i dont know how things should be done here. i just read some of the posts and followed the lead. secondly i wasnt angry but rather confused with some of the comments i received.

anyway, now i know and again Thank you.

migueros · Aug 31, 2015

i have another question, shall i use first person in writing an incident report? for instance:

" I found mr. RD lying on the floor ....."? or shall i use " nurse migueros ( which is me ) found mr rd lying on the floor..."?

i am getting confused on how to do a narrative incident report. thank you.

Jensmom7, BSN, RN · Aug 31, 2015

i have another question, shall i use first person in writing an incident report? for instance:
" I found mr. RD lying on the floor ....."? or shall i use " nurse migueros ( which is me ) found mr rd lying on the floor..."?
i am getting confused on how to do a narrative incident report. thank you.

Don't over think it. Remember the same questions you would ask if you were a reporter: Who? What? When? Where? Sometimes you can add Why? and How? but only if the incident was witnessed by someone or the patient is oriented and able to tell you.

I usually started the narrative with a basic "Patient sustained unobserved fall, found by (name, title)". Then list anyone else who may also have been involved in the discovery. That's Who and What.

"Patient had been observed (in bed, chair, whatever) at (time). Was found on floor next to her bed at (time). That's When and Where. Hopefully, everyone is doing their rounds. Do NOT fudge times!

If the patient is awake and alert, and able to tell you what happened, you can describe it. "Patient stated she was in bed, reached for her garbage can, started to fall and could not catch herself". Whatever she tells you. That's the Why and How. If she's confused or groggy, you may not be able to get those answers. That's ok.

Then, you add your assessment, and say who you notified. Include any tests ordered by the MD. Also if family or POA were notified.

The same information should go into your narrative note in the chart, except you don't mention the incident report. I believe they're discoverable anyway, should it come to that, but stick to the truth and no worries.

enuf_already · Aug 31, 2015

For the contusion on the forehead...where on the forehead and what size was it noted to be? Same for the skin tear on the elbow. How big was it?

Always document who you notified and when as well as if there were any witnesses.

The purpose of a narrative vs a form is that you can get more detail into a narrative report. A form may give you prompts and a small space to write a brief answer.

I'm sure you were asked to do a narrative because your instructor wants to see how detail oriented you are and if you understand the purpose of noting and stating the facts as they were.

An incident report would help you to recall facts if ever you landed in court. It can also be used to correct acute or chronic problems that cause incidents within an institution.