Who is in charge of making the incident report?

[lvnnars1]

for example, if a new skin discoloration or skin tear/open area is found on a patient and the supervisor was the person it was first reported to, is it that person's responsibility to make the incident report? Also, if that person was the one who received a T.O for a treatment order for the new skin problem, is it that person's responsibility to write down on the 24 hour book or is it the charge nurse for that station?

[canesdukegirl, BSN, RN]

I believe that an incident report is made by the person who assessed the condition. Yes, you should inform the charge nurse if that is the protocol for your facility, but ultimately the assessor is the one who should fill out the incident report. You should check on the policy at your facility.

[Blackcat99]

In LTC, it is suppose to be reported to the charge nurse and then the charge nurse is suppose to write the incident report. Example- If a CNA finds something and reports it to the DON, the DON will report it to the charge nurse and then the charge nurse will fill out the incident report. I use to work in LTC. It would make me furious when my CNA's would wait until the last 15 minutes of the shift to tell me "Oh I forgot to tell you that so and so's butt now has a great big bruise on it." So then of course, I would get stuck staying over and having to write out an incident report.

[merlee]

Every facility has its own policy for writing up the incident reports, but the person who takes an order should be responsible for whatever is needed to get the order recorded.

Seems to me that the first person who is capable of assessing the pt appropriately should be writing the incident report - placement, color, size, etc.

[casi, ASN, RN]

You find it, you write the report.

[linearthinker, DNP, RN]

Agree w/ Casi. As for the 2nd scenario, it is the responsibility f the person who took the order. Someone is trying to dump their responsibilities on you, don't let them, hold them accountable.

[Forever Sunshine, ASN, RN]

It would make me furious when my CNA's would wait until the last 15 minutes of the shift to tell me "Oh I forgot to tell you that so and so's butt now has a great big bruise on it." So then of course, I would get stuck staying over and having to write out an incident report.

I freaking hate that. I'm very approachable before 10pm. After that.. they are crossing hot coals. I should make them call the doctor. lol

[CoffeeRTC, BSN, RN]

sounds like miscommunication?

[P_RN, ADN, RN]

the 1st person who sees-reports and ONLY what he/she sees-not what she was told.

[ktwlpn, LPN]

for example, if a new skin discoloration or skin tear/open area is found on a patient and the supervisor was the person it was first reported to, is it that person's responsibility to make the incident report? Also, if that person was the one who received a T.O for a treatment order for the new skin problem, is it that person's responsibility to write down on the 24 hour book or is it the charge nurse for that station?

Are you one of the floor nurses? Are you saying that a cna reported a skin tear to a supervisor instead of to you? That is a real problem if that is the case. They need to promptly report any change in a residents condition to the nurse caring for that resident. Where I work the floor nurse would be completing that incident report while the supervisor continued on her way (getting report from 9 units,dealing with any issues involved and handling staffing issues) after she spoke to the cna about her inappropriate actions. As for the treatment order it's ultimately up to the charge nurse to make sure protocol was followed. Our supervisors would not have called for the order. Some of the charge nurses I have worked with do not want any other nurses adding anything to the 24 hour report-they want to do it all.

[Blackcat99]

Every facility has its own policy for writing up the incident reports, but the person who takes an order should be responsible for whatever is needed to get the order recorded.

Seems to me that the first person who is capable of assessing the pt appropriately should be writing the incident report - placement, color, size, etc.

Yes, it makes sense that whoever actually witnessed the event would be writing up the incident report. Not at the LTC's and assisted living facilities where I have worked. In fact, at the assisted living facility a patient had a fall while I was at lunch. The RN supervisor who witnessed the fall and assessed the patient refused to do the incident report. She said she wasn't going to do it and that it was my responsibility as the "charge nurse" to fill out the incident report.:mad:

[gentlegiver, ASN, LPN, RN]

I work LTC, if one of my patients is discovered to have an injury/bruise, by a CNA or another Nurse it is to be reported to me. It is my job to evaluate the problem, contact the correct people and family members. If my Co-Worker is nice enough to answer the phone and take a treatment order from the DR (written directly onto a telephone order sheet), I am grateful that I was not called away (again) from my rounds and happily will include the order in my notes and on the 24 hour report. While paperwork is a PIA, it is a necessary evil that we all must bowdown to. My Patient = My Paperwork