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What to include on the incident report

Long-Term Care Nursing Advisor, August 22, 2008

The incident report for an accident or injury such as a fall should include the following information:

  • Circumstances of the incident
  • Date, time, and location of fall, and during which shift and on what unit the fall occurred
  • Witnesses', staff members', and resident's accounts of the incident
  • Interventions taken to care for the resident immediately after the incident
  • Notifications made as a result of an incident
  • Resident symptoms prior to the incident
  • Vital signs and observations made after the incident
  • Resident activity at the time of the incident
  • Injuries/medical problems associated with the incident
  • Environmental hazards or faulty equipment contributing to the incident
  • Presence of any new incident risk factors
  • Corrective actions taken to reduce the likelihood of another incident

This excerpt was taken from Clinical Documentation: An Essential Guide for Long-Term Care Nurses written by Barbara Acello, RN, BSN.