Final answer:
No, nurses should not document anything concerning the completion of an incident report in the client's medical record. Incident reports are internal and are used for quality improvement, not for inclusion in official medical records.
Step-by-step explanation:
The question is whether a nurse should document anything concerning the completion of an incident report in the client's medical record. The answer to this question is No. An incident report is an internal document aimed at alerting hospital administration to the occurrence of something out of the ordinary. This report contains information about adverse events or errors that have occurred and is used for quality improvement purposes. It is not part of the patient's official medical record and should not be mentioned or documented there. Documenting the completion of an incident report could unintentionally expose the healthcare setting to legal risk and violate the patient's privacy.
When review is conducted with the team, elements such as the procedure name, needle and instrument counts, labeling of specimens, and equipment issues are indeed confirmed aloud but these discussions and the incident report details themselves are kept separate from the medical record. The focus within the medical record should remain on factual, objective description of the client's health status and the care provided.