INCIDENT DOCUMENTATION & REPORTING

1. INCIDENT DOCUMENTATION&REPORTING

2. OBJECTIVES • At the end of this session, the participants will be able to: • Define incident, accident, abuse and negligence • List what should be reported on an incident report • Explain what should be documented on an incident report • Explain time lines for reporting incidents • Complete an incident report accurately

3. DEFINITIONS • Incident – An event or occurrence • Accident – any event that happens unexpectedly, without a deliberate plan or cause • Misappropriation - intentional, illegal use of the property or funds of another person for one's own use or other unauthorized purpose

4. DEFINITIONS • Abuse – infliction of physical or mental injury on an adult by other parties, including but not limited to such means as sexual abuse, abandonment, isolation, exploitation, or extortion of funds, or other things of value, to such an extent that his health, self-determination, or emotional well-being is endangered. • Neglect - failure, by a caregiver responsible for an adult's care or by other parties, to provide the proper or necessary support or medical, surgical, or any other care necessary for his well-being. No adult who is being provided treatment in accordance with a recognized religious method of healing in lieu of medical treatment shall for that reason alone be considered to be neglected or abused.

5. WHAT SHOULD BE REPORTED • An accident or an injury • Physical, psychological, sexual or financial abuse; misappropriation of property • Assault, battery, false imprisonment or involuntary seclusion • Neglect, including missed appointments • Substance abuse

6. WHAT SHOULD YOU DOCUMENT? • These reports provide information about what happened • Describe the incident and all related facts • Give objective information (what you heard, saw, smelled and touched) • Follow the same guidelines as in progress report documentation

7. WHEN SHOULD INCIDENTS BE REPORTED ? • As soon as possible after the incident, once you have obtained help and/or the consumer is safe • Know your agencies policies and procedures for reporting incidents/accidents • Know who you are supposed to notify in the event of an incident/accident

8. INCIDENT REPORT “DO’S” • Answer: Who? What ? Where? When? How? • Record facts and objective information • Include all important details • Indicate the type of incident • Use complete sentences and correct grammar • Sign your name • Put time and date • Indicate action taken and any necessary follow-up • Document notification of supervisor

9. SAMPLE INCIDENT REPORT • Date: ________ Time: ________ Program: ________ • Staff involved:_______________________________________________________ • Consumers: _________________________________________________________ • Other people: _______________________________________________________ • Location: ______________________ Incident reported to: __________ • Type of incident: ____ Personal Injury ____ Emergency Room ____ Worker’s Comp • ____ Vehicle ____ Hospitalization ____ General Liability ____ Police Notified • ____ Other Property ____ Death ____ Behavioral Episode • Brief description of incident: _________________________________________________________ • _________________________________________________________________________________ • _________________________________________________________________________________ • Action taken: _______________________________________________________________ • Follow-up required: ___________________________________________________________ • Signature:__________________ Job Title: ________ Date: _______ Time: ____ • Administrator:________________ Job Title: ________ Date: _______ Time: ____

10. PRACTICE ASSIGNMENT • Complete an incident report using the information on the next 2 slides

11. INCIDENT REPORT EXERCISE • Today you arrived for work. You knocked on the door and no one answered. You heard shouting and opened the door using the emergency key. When you opened the door, Phil and CJ were fighting on the floor. Phil’s nose was bleeding and he was on top of CJ with his fist back. You yelled stop and Phil turned to look at you. CJ pushed Phil onto the floor and ran to his room.

12. INCIDENT REPORT EXERCISE • Nicole wanted to go to the Winn Dixie store to purchase cigarettes. You and Nicole walk to the store two blocks away. You are looking at magazines while Nicole is shopping for a few personal items. Nicole checks out at the register and signals to you that she is done. Both of you are leaving the store. The manager walks up to Nicole at the door and tells her to please come back inside that he was going to call the police. You ask why and he says you are an accomplish to the shop lifting so he will press charges against you also.

13. SUMMARY • Incident reports are legal documents • Always maintain confidentiality • Always report incidences as soon as they occur

14. THE END