The risk manager reviews an incident report completed by a nurse regarding a client's fall. Which finding in the report demonstrates inappropriate documentation?
The risk manager reviews an incident report completed by a nurse regarding a client's fall. Which finding in the report demonstrates inappropriate documentation?
A. The client's explanation of the event.
[15%]
B. Subjective factors preceding the fall.
[52%]
C. Any injuries sustained as a result of the fall.
[4%]
D. The names of all witnesses present.
[29%]
Statistics
Subject/Lesson
Subject
Leadership & Management
Lesson
Ethical/Legal
Client Need
Test Plan
Safety & Infection Control
Related Topic
Reporting of Incident/Event
Item Type
Item Type
Analysis
Explanation
Choice B is correct. The purpose of an incident report is to provide an objective account of an incident/occurrence, in order to identify issues with current practices, improve policies, and potentially investigate situations of negligence/malpractice. Subjectivity should be excluded from a report because subjectivity allows for opinions on details that may not be true (example, stating I believe the client fell because he did not follow instruction) would be inappropriate.
Choices A, C, and D are incorrect. An incident report should include the client's account of the fall (stated in quotations). An incident report should include any injuries sustained or adverse effects noted as a result of the fall and the monitoring and assessment performed following the event. An incident report should include the names of any witnesses to the fall.
Related Videos
2 Key Topics
Incident Reporting
15.3 Quality, Safety & Risk Management
Additional Info
Incident (sometimes termed occurrence or event) reporting is a tool to mitigate future risks. Incident reporting should also be completed for events involving clients and visitors. Such events include:
- Verbal and physical displays of aggression
- Tampering with medical devices
- Reports of sexual or physical abuse by staff
- Adverse reaction to a blood transfusion
- Client elopement
- Damage (or loss) of client possessions
- Falls or injuries
- Injuries related to a medical device
- Complaints
- Medication and treatment errors
- Interfering with client care
The incident should not be logged in the medical record or nursing notes. The documentation should be objective and factual and include what occurred, any injuries, if the provider was notified, care administered after the event, and any witnesses.
