Question

Which information would the nurse omit from written documentation when a reportable incident has occurred?

1.Names of witnesses on incident report
2.Nursing interventions in medical record
3.Time healthcare provider was called about incident report
4.That an incident report was submitted in medical record

Answer 1

In a reportable incident, the nurse should omit any mention of the incident report being submitted from the patient's medical record. Names of witnesses, nursing interventions, and the time the healthcare provider was called should be documented appropriately, but the incident report itself stays internal.

Step-by-step explanation:

When a reportable incident occurs in a healthcare setting, there is certain information that should be documented and other details that must be deliberately omitted for legal and privacy reasons. The information that a nurse should omit from the written documentation in the medical record is mention that an incident report was submitted. According to best practices in healthcare, an incident report is an internal document and should not be referenced in the patient's medical record. However, the names of witnesses may be included on the actual incident report, nursing interventions should be documented in the medical record, and it is important to note the time the healthcare provider was notified about the incident as part of the response action.