3.4.4 Incident Reporting and Forms

All unexpected situations leading to missed care, missed medication, injury or illness, destruction of or inappropriate functioning or misuse of equipment and other unforeseen issues causing disruption to services during care should be documented in an incident report. Incident reports are also written after any incident, even if no one seems to be injured. Incident reports are important documents that are used as support in legal cases that can occur after events of this nature.

A missing or improperly completed incident report can make a company vulnerable as there is no proof of what occurred and how the staff responded. Therefore, incident reports should be considered mandatory administrative duties.

Take a peek at the following two examples of incident reports. What information is required in each one? Take some time to do some Internet research to answer this question, and consider why each piece of information needs to be included.

To check your knowledge of the various documents that are found in a medical record, complete the following exercise. Remember, the names for these documents may vary from facility to facility.