General Incident Report in Nursing [Edit & Download]
1. Title
- Nursing Incident Report
2. Basic Information
- Date of Report: [Insert date]
- Time of Incident: [Insert time]
- Date of Incident: [Insert date]
- Location of Incident: [Insert location, e.g., patient room, nursing station]
- Reported By: [Insert name of the reporting nurse or staff]
- Role/Position: [e.g., RN, LPN, CNA]
3. Patient Information
- Patient Name/ID: [Insert patient name or ID number]
- Age: [Insert patient age]
- Gender: [Insert gender]
- Room/Ward/Department: [Insert location details]
4. Description of Incident
- Type of Incident: [e.g., medication error, patient fall, equipment malfunction, behavioral incident]
- Details of the Incident:
- What happened? (Provide a step-by-step account).
- Who was involved? (Include the names of staff, patients, or witnesses).
- When and where did it occur?
- What was the outcome? (Describe injuries, errors, or patient response).
5. Immediate Actions Taken
- Response by Nursing Staff:
- Describe interventions performed immediately (e.g., administering first aid, checking vital signs, stopping equipment).
- Notification of responsible parties (e.g., attending physician, nursing supervisor).
- Patient communication (if applicable).
6. Observations/Findings
- Environmental Factors: [e.g., wet floors, clutter, lighting issues].
- Staffing or Procedural Factors: [e.g., workload, miscommunication].
- Other Factors: Any additional context contributing to the incident.
7. Follow-Up Actions
- Steps taken to ensure patient safety (e.g., medical treatment, additional monitoring).
- Recommendations for preventing recurrence (e.g., policy updates, training).
- Communication with patient or family about the incident.
8. Attachments (if applicable)
- Include supporting documentation, such as:
- Photographs of the scene.
- Equipment maintenance records.
- Patient medical records (ensure HIPAA compliance).
9. Signatures
- Reported By: [Name, Signature, Date]
- Reviewed By: [Supervisor/Manager Name, Signature, Date]
10. Follow-Up Section (if applicable)
- Resolution Actions: Outline corrective measures taken.
- Date of Completion: [Insert date].
- Responsible Staff/Team: [Insert name and role].
General Incident Report in Nursing [Edit & Download]
1. Title
Nursing Incident Report
2. Basic Information
Date of Report: [Insert date]
Time of Incident: [Insert time]
Date of Incident: [Insert date]
Location of Incident: [Insert location, e.g., patient room, nursing station]
Reported By: [Insert name of the reporting nurse or staff]
Role/Position: [e.g., RN, LPN, CNA]
3. Patient Information
Patient Name/ID: [Insert patient name or ID number]
Age: [Insert patient age]
Gender: [Insert gender]
Room/Ward/Department: [Insert location details]
4. Description of Incident
Type of Incident: [e.g., medication error, patient fall, equipment malfunction, behavioral incident]
Details of the Incident:
What happened? (Provide a step-by-step account).
Who was involved? (Include the names of staff, patients, or witnesses).
When and where did it occur?
What was the outcome? (Describe injuries, errors, or patient response).
5. Immediate Actions Taken
Response by Nursing Staff:
Describe interventions performed immediately (e.g., administering first aid, checking vital signs, stopping equipment).
Notification of responsible parties (e.g., attending physician, nursing supervisor).
Patient communication (if applicable).
6. Observations/Findings
Environmental Factors: [e.g., wet floors, clutter, lighting issues].
Staffing or Procedural Factors: [e.g., workload, miscommunication].
Other Factors: Any additional context contributing to the incident.
7. Follow-Up Actions
Steps taken to ensure patient safety (e.g., medical treatment, additional monitoring).
Recommendations for preventing recurrence (e.g., policy updates, training).
Communication with patient or family about the incident.
8. Attachments (if applicable)
Include supporting documentation, such as:
Photographs of the scene.
Equipment maintenance records.
Patient medical records (ensure HIPAA compliance).
9. Signatures
Reported By: [Name, Signature, Date]
Reviewed By: [Supervisor/Manager Name, Signature, Date]
10. Follow-Up Section (if applicable)
Resolution Actions: Outline corrective measures taken.
Date of Completion: [Insert date].
Responsible Staff/Team: [Insert name and role].