INCIDENT REPORT Incident reports are records of unusualor unexpected incidents that occur inthe course of a clients treatment.

.I n c i d e n t r e p o r t s a r e i n a d v e r t e n t l y disclosed to the plaintiff are no longer c o n s i d e r e d c o n f i d e n t i a l a n d c a n b e subpoenaed in court.Thus, a copy of an I.R. should not be lefton a chart. DOCUMENTATION D o c u me n t a t i o n i s a n y wr i t t e n o r electronically generated information abouta client that describes the care or serviceprovided to that client. Health records mayb e p a p e r d o c u m e n t s o r e l e c t r o n i c documents, such as electronic medicalr e c o r d s , f a x e s , e mails, audio or videot a p e s a n d i m a g e s . T h r o u g h documentation, nurses communicate their o b s e r v a t i o n s , d e c i s i o n s , a c t i o n s a n d outcomes of these actions f o r c l i e n t s . Documentation is an accurate account of w h a t o c c u r r e d a n d w h e n i t o c c urred.N u r s e s ma y d o c u me n t i n f o r m a t i o n pertaining to individual clients or groups of clients. A . G U I D E L I N E S F O R G O O D DOCUME NTATION A document or chart must be written in F-L-A-T to protect nurses to berepeated to the jury for several times. F: A d o c u m e n t s h o u l d b e FACTUAL, w h a t y o u s e e , n o t w h a t y o u get. L:

A d o c u m e n t s h o u l d b e LEGIBLE , with no erasures. Correctionsshould be made as you have been taught.With a single line drawn through the error and initialled. A: A d o c u m e n t s h o u l d b e ACCURATE a n d c o m p l e t e . W h a t c o l o r was the drainage? How many times wasthe practitioner notified of changes. T: A document should be TIMELY ,completed as soon after the occurrencea s p o s s i b l e . L a t e e n t r i e s s h o u l d b e avoided or kept minimum. B. F O R M S O F N U R S I N G DOCUMENTATION T h r e e c o m m o n d o c u m e n t a t i o n forms - focus charting, SOAP/SOAPIERa n d n a r r a t i v e d o c u m e n t a t i o n a r e described in the following sections. Any of these methods may be used to documenton an inclusion or exception basis. 1 . F O C U S C H A R T I N G With this method of documentation, thenurse identifies a focus based on clientconcerns or behaviours determined duringt h e a s s e s s m e n t . F o r e x a m p l e , a f o c u s could reflect: A current client concern or b e h a v i o u r , s u c h a s d e c r e a s e d u r i n a r y output. A change in a clients condition or behavior, such as disorientation to time,place and person. A significant event inthe clients treatment, such as return froms u r g e r y . I n f o c u s c h a r t i n g , t h e

a s s e s s me n t o f c l i e n t s t a t u s , t h e interventions carried out and the impact of the interventions on client outcomes areo r g a n i z e d u n d e r t h e h e a d i n g s o f d a t a , action and response. Data: S u b j e c t i v e a n d / o r o b j e c t i v e inf ormation that supports the stated focusor describes the client status at the time of a significant event or intervention. Action: Completed or planned nursingi n t e r ventions based on the nurse s assessment of the clients status. Response: Description of the impact of the interventions on client outcomes. 2.S O A P / S O A P I E ( R ) C H ARTING SOAP/SOAPIER charting is a problemoriented approach to documentat i o n whereby the nurse identifies and listsc l i e n t p r o b l e m s ; d o c u m e n t a t ion thenf o l l o w s a c c o r d i n g t o t h e i d e n t i f i e d problems. Documentati on is generallyo r g a n i z e d a c c o r d i n g t o t h e f o l l o w i n g headings: S = subjective data (e.g., how does theclient feel?) O = objective data (e.g., results of thephysical exam, relevant vital signs) A = assessment (e.g., what is the clientsstatus?) P = plan ( e . g . , d o e s t h e p l a n s t a y t h e same? is a change needed?) I = intervention (e.g., what occurred?what did the nurse do?) E = evaluation ( e . g . , w h a t i s t h e c l i e n t outcome following the intervention?) R = revision ( e . g . , w h a t c h a n g e s a r e needed to the care plan?) Similar to focus charting, flow sheets andc h e c k l i s t s a r e f r e q u e n t l y u s e d

a s a n adjunct to document routine andongoing assessments and observations. 3.N A R R A T I V E C H A R T I N G - Narrative charting is a method in whichnursing interventions and the impact of these interventions on client outcomes arerecorded in chronological order covering aspecific time frame. Data is recorded inthe progressn o t e s , o f t e n w i t h o u t a n o r g a n i z i n g framework. Narrative charting may standalone or it may be complemented by other tools, such as flow sheets and checklists. C . L E G A L G U I D E L I N E S I N DOCU MENTATION The following principles are intended toprovide nurses and midwives with clear direction for producing and ma intaininghigh quality, defensible documentation: 1 . D o c u m e n t f a c t - F a c t i s w h a t t h e n u r s e s a w , h e a r d or did in relation to the patient's care andc o n d i t i o n . T h i s i s w h a t shoul d be documented. Nurse s and midwivess h o u l d a v o i d n o n c o m m i t t a l documentation. A n e x t e n s i o n o f t h i s principle is that nurses should write healthcare records objectively. Irrespectiv e of where the nurse or midwife is recordingi n f o r m a t i o n , t h a t i s t h e n u r s ing notes,i n c i d e n t f o r m s o r s t a t e m e n t s ,

documentation should always remain factual and objective and not subjective or emotive.

2 . D o c u m e n t a l l r e l e v a n t inform ation T h i s w i l l b e d i c t a t e d b y c o n s i d e r a t i o n o f t h e i n d i v i d u a l circumstances of each patient. Nurses'and midwives' documentation should bemade with respect to the total condition of the patient, not just a clinical specialty. Inparticular, nurses and midwives shoulddocument any change in the condition of the patient and who was notified of such achange. Nurses and midwives should alsodocument whether the patient's conditionh a s r e m a i n e d u n c h a n g e d d u r i ng their shift, as responsibility for t h e p a t i e n t i s handed over with each change of shift.3. Document contemporaneously Nurses and midwives shouldr ecord entries in the patient's notes a s soon as possible after the events to whichreference is being made have occurred,w i t h t h e d a t e a n d t i m e f o r e a c h e n t r y recorded. All entries should also includethe author's signature, printed name anddesignation. This clearly indicates whenthe record was made and by whom ande n s u r e s m o r e r e l i a b l e d o c u m e n t a t i o n . Nurses and midwives should never pre-date or pre-time any entry on a patient'sc h a r t . I f a n o b s e r v a t i o n i s m a d e o r a medication is given at a certain time, thattime should be recorded on the chart. 4 . M a i n t a i n t h e i n t e g r i t y o f documentation This principle refers to the requirement topreserve all that is recorded in a patient'srecord, even if an error is made. Nursesa n d m i d w i v e s s h o u l d n o t a t t e m p t t o change or delete err o r s m a d e i n t h e patient's notes. An attempt to change or delete an entry could be interpreted as ana t t e m p t t o c o v e r u p e v e n t s o r m i s l e a d others. The error should be left so

that it islegible, with a single line through it, andinitialled. The correct entry should then ber e c o r d e d o n t h e n e x t l i n e o r c o l u m n . Documentation should not include breaksb e t w e e n e n t r i e s ; t h i s e n s u r e s t h a t information cannot be ad d e d a f t e r t h e fact.