Read the incident case report and fill out the incident report worksheet.
When completing the incident report form remember you are -all of you-David Ortiz, the student nurse.
Therefore, you will document -in your incident report only: What David did-assessment & the findings,
what he saw, what he overheard, or what the patient told him. You need to write on the third person; you
document only facts, you do not place blame/judgment on any one. Do not document what other health
care providers did.
The incident report is a legal document, separate from the Medical Record. You do not state in th medical
record that you wrote an incident report. You send the incident report to QA or Risk Management Dept.
for further investigation. Lastly, make sure to sign the document as: David Ortiz/Your name.