An adverse event has occurred with resident injury: what should be documented in the medical record and what information should be documented on other business documents?

The Institute of Healthcare Improvement defines an adverse event as an “unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment), that requires additional monitoring, treatment, or hospitalization, or that results in death.”*

1. Medical Record Documentation

2. Incident Report

3. Investigative Notes

4. Disclosure of Error Conversation and Documentation

5. Employee Personnel File

*Agency for Healthcare Research and Quality. Adverse Events,
Near Misses, and Errors. [Updated July 2016].

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