Week 3 DQ 2 Keeping It Real
What do you think is the reasoning for not filing incident reports in medical records? Provide examples of three incidents and explain why they could be problematic in patients’ files.
The purpose of an incident report is not to produce information for the patient's record. The purpose of an incident report is to inform risk management of the issue, and quality improvement of areas to be evaluated.
If there is some part of the incident which needs to be in the patient's record, such as what occurred, and what was done to remedy the incident, that should be recorded. The fact that an incident report is filed does not affect the patient's care, and is therefore not germane to the record. When the floors are mopped, and the bathrooms are cleaned in the patient’s room, it affects the patient, but it is a hospital issue, and does not affect the care, so a record of that is also not appropriate in the record.
Some of the reasons that incident reports are not filed when they should be are somebody deliberately does not want the incident to be reported, somebody didn't think the incident was of credible importance to be reported, or filing an incident report was simply forgotten about. The first example of why not filing an incident report could be problematic is in when a patient has been given their latest round of medication. If the dosage has been given to the patient but this dosage has not been noted in the incident reports, this could lead to the dosage being issued again. This would be very dangerous and potentially lethal for that patient. Another example would be if it has been discovered that the patient has an allergic reaction to a particular medicine or food which is then given to them unknowingly. Of course, medical records will often highlight this information, but if it is something that is only discovered later on, it is important that all of the staff caring for that patient is well aware. The final example could...
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