Nursing Documentation
Let's Learn Nursing Documentation
Incident Reports
- Only person directly involved should fill it out
- Only facts: No opinions, no blaming.
- Do not document in chart about the incident report.
- Follow chain of command for reporting incident.
- Do not alter record
- Be honest, descriptive, and objective
Do
- Know they are important in identifying risks
- Be honest and objective
- Inclient the client’s account
- Fill out an incident report even if it occurred to a visitor.
- Include date and time and your objective observations.
- Follow the chain of command for reportin incident.
Do Not
- Make reference to incident report in client’s chart.
- Copy or place the incident report in client’s chart.
- Fill out a report for someone else.
- Document judgements and/or opinions
Visitor Fall
Patient fall
Medical Error
Cardiac Arrest
