Question

A client fell in the clinic during the intake process. The ambulatory care nurse is documenting the occurrence. Which of the following indicates proper documentation of the incident?

A. Document the incident in the patients chart
B. Make no mention of the fall in the clients charts
C. Report it the the risk management and they will document the incident
D. Document the occurrence of the fall in the organization's incident reporting system

Answer 1

The correct documentation of a client falling in the clinic is to record the occurrence in the organization's incident reporting system, which is used for quality improvement and risk management.

Step-by-step explanation:

The proper documentation of an incident, such as a client falling in the clinic, involves recording the occurrence in the organization's incident reporting system. This system is separate from the patient's medical chart. The incident report should include specific details such as the time and location of the fall, a description of the incident, actions taken following the incident, and any interventions made. It is important not to document the incident within the patient's medical chart, as the incident report is used for internal quality improvement and potential risk management issues.

While reporting the incident to risk management may be a part of the protocol, it is also essential for the nurse to document the occurrence in the designated incident reporting system, which is often a standard procedure in healthcare organizations to track and analyze incidents for improving safety and care.