Incident report is a legal and official document outlining a detailed account of events that occurred during an incident.It is common in medical profession to encounter incidents relating to patients like patient fall or relating to nurses like a stitch accident.In such a situation,the incident report is important in providing detailed information relating to what happened,guide the hospital in planning an appropriate corrective action and protect the hospital from legal liability in case the patient decides to seek legal action.According to America Nurse Association policy on writing incident reports,it is recommended that the report should be written as soon as possible after the situation has been controlled.Preferably,it should be recorded before 24 hours lapse when the details of the events are still clear in the mind of the victims.This article provides strategies that should be followed when writing an incidence report.
Follow the required laid down protocol
Every organization has a guideline detailing how to record incident report and this should be followed by the individual writing the report.As soon as the situation is under control,obtain the required documents like the forms and start filling out.Ensure the report details only the facts and not personal opinion.The facts include details of the place of occurrence of the event, time and date,details of all members of the organization who were present as well as the details of the individual writing the report.In-case there were witnesses,get them to fill out their forms as well but don’t force them if they are not willing to.Any other evidence available should be documented and included as part of the report .
The incidence report is written to be presented to third parties.The contents of the report must be accurate,realistic and objective if it is to be adopted by third parties.The report should outline only the events which occurred without trying to blame anyone for the situation.In case the incident involved a fall by the patient,record what the patient said during the incident,and whether any injuries occurred as a result of the fall.If anyone was in the vicinity record it with an explanation why he/she was in the place at that specific time.Record the action taken to contain the situation for instance if the patient was helped to bed and first aid performed on the patient.
Describing the event
This is the most important part of the report.Here, a record the events is outlined using first person narrative giving a chronological account of the first event to the last one.The writer should use names in describing all the individual present as well as the actions taken by each individual.In other words,answer the question who,what,where,and when using names of individuals and places.Give a quotation of what each individual present said and how it relates to the incident.Also,the report should give a thorough presentation by giving as much details as possible,this is the reason why the report is written as soon as possible when all the events are still clear.The language used should be clear with minimum use of ambiguous language by avoiding statements like “when she came in she was crying” as this will will create confusion.Further,the incident report should be written using simple language with minimum use of technical terms,abbreviations,short form or slang language.Words like SEO instead of scene of crime should be avoided.
Editing and submitting
After completing the report,there is need to proofread and edit to ensure all events are captured.The details of names of individuals and places should be double-checked to make sure they are accurate.In case witnesses agree to fill forms,there is need to ensure all the facts recorded by each individual match otherwise they report will be dismissed.Check for spelling and grammar errors before submitting and finally submit the report to the correct person like head of department.
A well designed incident report document may help create incident report. incident report template is an incident report sample that shows incident report layout, incident report outline and incident report format in the incident report example.