General Incident Report in Nursing

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].