How to document any incident
If you work in human services, whether you are a social worker, healthcare professional, child care worker, or any other human service provider, you probably know that good documentation is an important part of your job. Documentation is not important just for claims concerns. Good documentation provides a detailed account of an incident so that appropriate follow-up actions are taken, patterns and trends are identified, policies and procedures can be evaluated, and steps can be taken to improve the safety of everyone at your facility.
According to a Sentinel Alert issued by the Joint Commission in 2010, the number of violent incidents in healthcare settings, some as serious as assault, rape and homicide, has risen steadily in recent years. These crimes are committed by patients, visitors and other intruders of the institution.
When these incidents occur, the Joint Commission recommends a number of actions, including reporting violent activities or perceived threats as soon as possible, to either the facility management or the police. Proper documentation is crucial to ensure incidents are handled properly.
Like any skill, good documentation takes practice. Here are some tips to make your task a little easier.
Know what to document. If you are unclear on what types of incidents require documentation, check their policies and procedures, or ask your supervisor. Make sure you know which situations require a full incident report and which only require “charts” or “logs” of some kind.
Avoid delays. Incident reports should always be written as soon as possible after an incident occurs. Time quickly darkens our memories. If you wait days, or even hours, before writing your report, you will start to forget information that may be important. In addition, the stories of other people involved or who witnessed the incident can easily stain memory. After hearing such stories, it becomes difficult to distinguish your own memories from those of others. Inadvertently, honest people will start to change their stories, fill in the gaps, and add extra bits of “post-incident information.”
Although it is important to provide emotional support to those who have been involved in a violent incident, try to minimize your conversations with other people involved until all parties have been interviewed or have written a report of the incident.
List the basic facts of the incident chronologically. Answer the who, when, where, what, how and why questions. Include events that led to the incident. Describe all attempts to intervene, verbally or physically.
Be objective. Stick to the facts. Avoid subjective comments or opinions. Make a distinction between personal knowledge and what you have learned from others. Don’t try to blame or protect other people. Avoid labeling a person’s mental or emotional state. For example, if you believe that a person involved in an incident was intoxicated, describe the behavior or other signs that led you to that conclusion, rather than simply labeling the person “drunk.”
Be precise, concise and clear. Be as brief as possible, but include the necessary information. Check the names, addresses, dates and times. Check your grammar, spelling, and punctuation. Always make a draft, review it, and then prepare your final report.
After a crisis, it is essential to evaluate what has happened and to look for ways to prevent or minimize future events. Your well-written incident report is an important tool in this process and a way to improve the safety of everyone who may be involved in times of crisis.