The client climbed over the side rails of his bed and fell to the floor, and an incident report needs to be completed. Which of the following is involved in the correct reporting of an incident?
a. The nurse who witnessed the event completes the report.
b. Details of the incident are subjectively described.
c. An explanation of the possible cause for the incident is entered.
d. A notation is included in the medical record that an incident report was prepared.
A
The nurse who witnessed the incident is the one who completes the report. An incident is any event that is not consistent with the routine operation of a health care unit or routine care of the client. The incident report outlines circumstances that led to client injury or risk of injury, and falls is an example of when an incident report would need to be completed.
Details of the incident should be objectively, not subjectively, described on the incident report.
An explanation of the possible cause is not included in the incident report. The sequence of events is described objectively.
A notation that an incident report was written is not included in the medical record.
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