Documenting Patient Falls

You document the fall, every fall, in the medical record. Just the facts. Interventions taken.

You should also document an incident report. We use Midas at our facilities. We are told to not mention/document the incident report into the medical record.

Facts only in medical record. NEVER mention an incident report in a medical record. Document the people notified according to your facility policy ( usually the doctor and be sure to use the name of the doctor, family as appropriate, charge nurse, etc ).

I find it ludicrous that we're not supposed to say "incident report" in the nursing notes. Everyone in the world knows that one must be generated for any and all falls.

The DOH and the lawyers all know that too. So what/why are we supposed to be keeping it so secret?!?! Even though incident reports are considered 'in house' documents, I was always under the impression they could be subpoenaed if the DOH/lawyers ask for them. (I'm sure there will be disagreement on this fact.)

The incident report is just part of the in-house investigation and it gets counted into the monthly/quarterly statistics. So again, what's the big secret?

Never made sense to me when I started in the mid 1970's and when I retired.

Most lawyers know about incident reporting systems so if there is a lawsuit they will ask for the incident report as well as the medical records. It is up to the FoI people to assess what parts of the RCA or IDCR to redact.

amoLucia,

As it was taught to me:

The issue is let's say there is an "aberrant happening" - something less obvious than a fall. The typical example is something that is unusual but inconsequential (no harm to patient). You have a choice to put a huge red flag in the chart for someone to make a big deal of, or not.

Example: I start an 18g L AC IV for a patient going to run-of-the-mill surgery and document it. Pt comes back from case and amongst the notes it says, "Art line L brachial d/c'd."

That's a little different than, "Blood backflowed from L AC site all the way to IV bag when pt transferred to OR table. Brachial a. line D/C'd and incident report filed."

As you note, they can be subpoena'ed - but not if no one knows to ask for them, and if they don't recognize the charted situation as one that might have compelled an incident report, they won't be asking.

I am confused on "You walk into patients room and find him on the floor, you assist him back to safety and turn bed alarm on, then you must record the event in?" The book says medical record and incident report but I thought you NEVER document that kind of stuff in the medical record ??

You aren't supposed to document that an incident report was filed but you do document the objective data. "Upon RN arrival into Mr. Jones' room at 19:00, pt was noted to be on the floor. Pt conscious, unable to state what happened, assisted back to bed, bed monitor applied, MD notified."

It is up to the FoI people to assess what parts of the RCA or IDCR to redact.

Could you explain this further please?

amoLucia,

As it was taught to me:

The issue is let's say there is an "aberrant happening" - something less obvious than a fall. The typical example is something that is unusual but inconsequential (no harm to patient). You have a choice to put a huge red flag in the chart for someone to make a big deal of, or not.

Example: I start an 18g L AC IV for a patient going to run-of-the-mill surgery and document it. Pt comes back from case and amongst the notes it says, "Art line L brachial d/c'd."

That's a little different than, "Blood backflowed from L AC site all the way to IV bag when pt transferred to OR table. Brachial a. line D/C'd and incident report filed."

As you note, they can be subpoena'ed - but not if no one knows to ask for them, and if they don't recognize the charted situation as one that might have compelled an incident report, they won't be asking.

I was taught not to refer to incident reports in the medical record. However, on a separate subject, I respectfully disagree with not documenting the art line blood backflow in the patient's medical record. The difficulty I have with this is that part of the patient's clinical situation is selectively omitted by the nurse, and my understanding is that as nurses it is our duty to render an accurate, i.e. sufficiently detailed objective record of patient events, including adverse events, in their medical record. The patient has the right to expect this, and this documentation could be pertinent to the patient's care postoperatively, when other health care team members will be reading the OR report and assuming care of the patient.

Even if this event has no negative effect on the patient my understanding is that it should still be recorded in sufficient detail on their record. I do not believe we can legally take it upon ourselves to decide to omit this information from the medical record. To my mind that is falsification of the medical record by omission of data, even though the art line is mentioned in the medical record.

^ Generally-speaking I agree with your sentiment. There's a fine line between omitting imporant things and documenting a situation carefully with only relevant facts.

The opposite is also true, though, which is that due to ignorance, fear, whatever else, there are many notes that are written in an unnecessarily inflammatory tone or detail. Those are not necessary either.

It could be argued that the example I gave could/should be documented this way: "Blood backflow noted in NS line when patient transferred to OR table. Line flushed and L brachial a. site D/C'd. Pressure applied ___ mins. No active bleeding at site."

It's very straightforward, and absolutely nothing else is needed. If the surgery had proceeded with some untoward effect to the patient due to that line, that's a different story and should be documented as such.