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How to Signature Quality Incident Record

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The definition of an incident is something that happens, possibly as a result of something else. An example of incident is seeing a butterfly while taking a walk. An example of incident is someone going to jail after being arrested for shoplifting.
An incident in the workplace is an unplanned event that doesn't result in injury, but does cause damage to property, or has enough significant risk to merit recording.
ITIL 2011 defines an incident as: an unplanned interruption to an IT service or reduction in the quality of an IT service or a failure of a Configuration Item that has not yet impacted an IT service (for example failure of one disk from a mirror set). Incidents are the result of service failures or interruption.
Write objectively. Describe exactly what you saw. Incorporate patient and witness accounts of the event into the report. Don't assign blame. Avoid hearsay and assumptions. Forward the report to the person designated by your facility's policy.
Write objectively. Describe exactly what you saw. Incorporate patient and witness accounts of the event into the report. Don't assign blame. Avoid hearsay and assumptions. Forward the report to the person designated by your facility's policy.
Assess the patient and record any bruises, lacerations, or abrasions. Describe any pain or deformity in his extremities, particularly his hip, arm, leg, or lumbar spine. Record vital signs, including orthostatic blood pressure. Document your patient's neurologic assessment.
An assessment for underlying new illness. A blood pressure and pulse reading when sitting, and when standing. Blood tests. Medications review. Gait and balance. Vitamin D level. Evaluation for underlying heart conditions or neurological conditions.
Generally, according to health care guidelines, the report must be filled out as soon as possible following the incident (but after the situation has been stabilized). This way, the details written in the report are as accurate as possible.
Provide the basic facts. If not, start the report with a sentence clearly stating the following basic information: The time, date and location of the incident (be specific; write the exact street address, etc.). Your name and ID number. Names of other members of your organization who were present.
Stick to the facts and not insert your opinions. Be descriptive and detailed. Use quotes from witnesses, victims and suspects when possible. Write in plain language so that anyone reading the report can easily understand it.
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