What should be documented after a patient experiences an incident?

Documenting an incident in an incident report is essential because these reports serve a critical role in capturing details about unexpected events or accidents that occur in a healthcare setting. An incident report allows for a thorough and systematic account of the situation, including what happened, the circumstances surrounding the event, and the action taken. This documentation is designed to collect factual information without assigning blame, ensuring that the incident can be analyzed for safety improvements and quality assurance.

Incident reports are generally kept separate from the patient’s medical record to protect patient confidentiality and ensure that the report can be used for internal review processes without influencing the patient’s ongoing care. This distinction is crucial for maintaining transparency while promoting a culture of safety. In the case of an incident report, the focus is on preventing future occurrences and improving workplace practices rather than detailing a single patient’s treatment or response.

While other documentation like patient charts and follow-up reports may include some information about the incident for continuity of care, they are not the primary nor the correct means to formally document such occurrences in a way that contributes to organizational learning and safety protocols.