Document brief, factual information about the event. Clinical information included on the incident report must also be noted in the medical record to ensure a complete record of clinical care provided. Do not note in the medical record that an incident report was completed.

Ensure incident reports are marked as “Confidential” documents. Consult with facility legal counsel for specific statutory protection language.

Quality Follow-Up – Quality assurance/performance improvement follow-up should be noted on a separate quality document that is marked as “Confidential”. Consult with facility legal counsel for specific statutory protection language. Quality follow-up documents should not be attached to the incident report.

The quality document provides an opportunity to review the details of the event and ask pertinent questions. Some examples include:

• Were facility policies and procedures followed? Are policy and procedure modifications needed to provide clarity to workflow processes?
• Were administrative and engineering controls in place and functioning properly? Were any administrative or engineering controls over- ridden or silenced?
• Has employee training and competency validation been provided related to this adverse event?
• Was the resident care plan being followed? Was the resident care plan appropriately modified to reflect current resident needs and risk of injury?
• Was this adverse event related to resident non-compliance?
• Was appropriate care and treatment provided post-event?
• Was appropriate communication provided post-event?