The nurse sees a visitor exit a client's room into the hallway and faint, falling on the floor unconscious. The nurse has the visitor taken to the Emergency Department, notifies the supervisor, and completes an incident report
The nurse's next action is to: 1. Document in the chart of the client whose room the visitor exited that an event occurred, and describe the event objectively.
2. Initiate a new client medical record for the visitor and document the event objectively.
3. Give the completed report to the nursing supervisor.
4. File the incident report in the chart of the client whose room the visitor exited.
3
Rationale 1: When a visitor to the hospital is involved in an event, the incident report is given to the nursing supervisor, just as it would be if the person involved were a client. The visitor should always be encouraged to be seen in the Emergency Department so that he receives immediate care for any injury he might have sustained. Nothing should be documented in the client's record, because the medical record only pertains to the client, not visitors. A medical record for the visitor will be initiated in the Emergency Department—the nurse does not initiate it.
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