Incident report

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In a health care facility, such as a hospital, nursing home, or assisted living, an incident report or accident report is a form that is filled out in order to record details of an unusual event that occurs at the facility, such as an injury to a patient. The purpose of the incident report is to document the exact details of the occurrence while they are fresh in the minds of those who witnessed the event. This information may be useful in the future when dealing with liability issues stemming from the incident.[1]

Generally, according to health care guidelines, the report must be filled out as soon as possible following the incident (but after the situation has been stabilized). This way, the details written in the report are as accurate as possible.[2]

Most incident reports that are written involve accidents with patients, such as patient falls. But most facilities will also document an incident in which a staff member or visitor is injured.

In the event that an incident involves a patient, the patient will often be monitored for a period of time following the incident (for it may happen again), which may include taking vital signs regularly.

The latest guidebook for the index of the International Classification of Diseases, Edition 10, Clinical Modifications (the ICD-10-CM, to be implemented in the fall of 2015 in the U.S.) has, in Chapter 20 (External Causes of Morbidity, Codes V00-Y99), a section of external cause codes to identify and track the occurrence of certain serious medical and surgical errors and other serious events, which could constitute malpractice and must always be reported immediately, in order to support the collection of data related to the National Quality Forum's never events, which was instituted with the help of the American federal government's Institute of Medicine (IOM). The federal and state governments use the never events list as the basis for quality indicators and state-based reporting systems. Some of these are: Y65.51 (Performance of the wrong procedure or operation on the correct patient); Y65.52 (Performance of a procedure or operation on a patient not scheduled for a procedure or operation); and Y65.53 (Performance of the correct procedure or operation on the wrong side or the wrong body part of the patient).

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