The Incident Report: Defensive Documentation Series Part 2

This is the second post in my defensive documentation series. Each post will provide new tips on how your documentation can protect you and your facility from litigation. This post focuses on the incident report.

All hospitals have some form of an incident report. This is an internal reporting document designed to be completed when there is anything that happens that has the potential to result in patient harm, or did result in patient harm. These reports are completed for many different types of things like medication errors, patient falls, visitor falls, near misses, or other out of the ordinary events that have potential to be problematic.

These reports are, for the most part, protected from discovery in litigation. In other words, the hospital does not have to produce these when they turn over medical records to attorneys in malpractice cases. This is important because the facility wants staff to feel comfortable completing these reports with as much detail as possible so that the facility can study what happened and take steps to prevent the incident from happening again.

What clinical staff often do not understand is that if, in your documentation, you mention that an incident report was completed that protection from discovery is gone. Now that the report has been mentioned in the medical record, that incident report is now discoverable.

This is often done innocently enough: "Patient slid from recliner landing on the floor on her left side. Patient examined and found to have area of swelling to tailbone, pt sent to x-ray, unit director notified, patient's husband notified, incident report completed, fall debriefing form completed. "

So, in this example the staff member has identified 2 internal reporting documents that would previously have not been discoverable but can now be requested to be included with the medical record: the incident report and the fall debriefing form. These forms often have loads of information on them describing exactly what happened, where the problem was that caused the incident, and all sorts of things that the facility is not going to want shared with plaintiff malpractice attorneys.

Make sure your clinical staff understand what should and should not be included in their documentation. Veritas MedLaw can come to your facility and present our defensive documentation course for your staff. In this course we spend a few hours making sure clinical staff understand the significance of the information they are recording in the patient's medical record and how the way it is done can either protect them and your facility or can inadvertently help out a plaintiff attorney preparing for a malpractice case. Contact us for more information on this course.