May 23, 2011
Who? – The employee/staff or volunteer person who discovers, witnesses, or to whom the event is reported should be responsible for documenting the incident.
What? – Be objective. Report only FACTS. Do not report conclusions, opinions, accusations or admissions of wrong-doing. Never place blame or point your finger.
The following details are important items that should be included in the report:
- Time, date, and location of the incident
- What happened and what effect it had on the individual(s) involved.
Example: “Individual fell on floor, right knee injured.”
- Medically relevant facts as well as environmental details relevant to the event
- a. Example: “Carpet is folded over
- Statement of the patient or witnesses regarding degree of injury and what happened
- a. Example: “I saw him trip over the carpet”
- Injuries as observed by medical personnel
- a. Example: “Right foot is rotated
- Information that indicates final outcome
Example: Results of lab work, x-rays, etc.
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