The patient has fallen when trying to climb out of bed. The nurse:
a. needs to complete an incident report as a risk management document.
b. completes an incident report since it is a permanent part of the medical record.
c. must document that an incident report was completed in the medical record.
d. should say nothing about the incident in the medical record.
ANS: A
Incident reports are objective, nonjudgmental, factual reports of the occurrence and its consequences. The incident report is not part of a medical record but is considered a risk management or quality-improvement document. The fact that an incident report was completed is not recorded in the patient's medical record; however, the details of a patient incident are documented.
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