In a health care facility, such as a hospital, nursing home, or assisted living, an incident report or accident report is a form that is filled out in order to record details of an unusual event that occurs at the facility, such as an injury to a patient. The purpose of the incident report is to document the exact details of the occurrence while they are fresh in the minds of those who witnessed the event. This information may be useful in the future when dealing with liability issues stemming from the incident.
Generally, according to health care guidelines, the report must be filled out as soon as possible following the incident (but after the situation has been stabilized). This way, the details written in the report are as accurate as possible.
Most incident reports that are written involve accidents with patients, such as patient falls. But most facilities will also document an incident in which a staff member or visitor is injured.
In the event that an incident involves a patient, the patient will often be monitored for a period of time following the incident, which may include taking vital signs regularly.
Purpose of an Incident Report
People often regard an incident report as a black mark against the nursing staff who wrote it. This should not be the case because an informed consent is a legal document of an incident that took place. The purposes of an incident report are the following:
- To document the exact detail of an accident or unusual incident that occurred in a health-care institution.
- To be used in the future when dealing with liability issues stemming from the incident.
- To protect the nursing staff against unjust accusation.
- To protect and safeguard the client in case of negligence on the part of the nurse.
- Helps in the evaluation of nursing care to ensure safe care to all patients.
- Written at the first opportunity after the incident so that the details are not blurry or forgotten.
- Written with a pen (ink) not pencil. Information written using a pencil can be erased.
- Details should be complete and accurate. The patient should be identified with the following details:
- Full name
- Hospital bed number
- Hospital ID
- Patients diagnosis
- Patient’s condition before and after the incident
- Details of ward or clinical area
- Date, time and place of incident
- Details of equipments used including the serial number or asset tag identification (if appropriate)
- Written as statement of facts without interpretation or opinion. Descriptive adjectives should not be used.
“Mr. Dimaano would not listen when I told him to stay in bed. He is very difficult to care for. It is his fault why he fell on the floor.”
You should write:
“I heard a loud crash, and immediately went to the ward. I found Mr. Dimaano on the floor.”
- Events should be written in sequence that they occurred.
- Proper technical terms should be used. For example instead of using the word bottle specify that it is a urinal.
- Identifies the witnesses.
- Identifies the medications given before the incident (if applicable)
- Identifies the equipment that is involved or used.
- Signed legibly with the correct designation.
