Documentation
Incident reports
File an incident report on any patient, submit it by signing, and have the clinical supervisor and an administrator review and close it.
An incident report records an event that affected a patient's safety or care: a fall, an injury, challenging behavior, elopement, a medication error, a physical hold or a concern about abuse or neglect. Every discipline uses the same report.
Filing a report#
- Open the patient's chart and choose Incidents under Clinical.
- Click New Incident Report.
- Choose the Episode the report belongs to. Its discipline picks the incident report template.
- Fill in what you know:
- What happened: the date and time, the Type, the Severity and a Description of events in order.
- Where and who: the Location and Setting, the exact place if it helps, the Staff involved and anyone else who was there. Turn on Someone was injured to describe the injury.
- Response: the Actions taken. Turn on Guardian or caregiver notified to record when, how and who you told, and Follow-up needed to describe what happens next and by when.
- Click Create Draft. The report opens as a document you can keep editing.
The date and time are in the time zone of the location you choose, or the clinic's time zone when you leave the location empty.
Submitting#
While the report is a draft, click Edit Details in its Incident section to change any field. When it is complete, click Sign. Signing needs the date and time, type, severity, description and actions taken, plus the details any yes answer asks for. Signing without a guardian or caregiver notification shows a warning but is allowed.
Once signed, the report is Submitted and its fields never change. To correct or add something, add an addendum.
States#
| State | What it means |
|---|---|
| Draft | Being written. The author can still change it. |
| Submitted | Signed by the author and waiting for the reviewers. |
| Under review | A reviewer started the review or signed it. |
| Closed | Every required reviewer signed and a reviewer closed it with a summary. |
Reviewing and closing#
After the author signs, the report waits for the signers its template asks for, listed under Other signers. They sign from the report or from Pending my signature on the Todos page. The first reviewer signature moves the report to Under review; someone with the Clinical: Document Approve permission can also click Start Review.
When every required signer has signed, a reviewer with that permission clicks Close Report and writes a Review summary of what the review found and what changes because of it.
An addendum on a closed report reopens it as Under review, so the change is reviewed too. The earlier summary is kept.
Follow-ups and the register#
Every incident report also appears in the clinic-wide incident register, beside staff incidents that involve no patient. Supervisors add follow-up tasks with an owner and a due date in the report's Follow-ups section; a report cannot be closed while any of them is open.
When no episode of care applies (for example, a fall before intake), file the incident under Incidents outside an episode on the same chart page instead. It is linked to the patient and reviewed in the incident register.
Default signers#
By default an incident report asks for the reporting staff member's signature, then the Clinical supervisor review and the Administrator review, both required. The clinical supervisor is the visit's supervising provider, the author's supervisor or the patient's care team lead; see Documents with several signers for who signs each.
The first incident report filed in a discipline adds an Incident report form to Setup > Clinical libraries > Templates. Edit its signature fields there to change who signs, add a signer or make one optional, then publish it. New reports use the published version; reports already filed keep theirs.