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Anecdotal AND Incident
Nursing (01)
Kerala University of Health Sciences
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NURSING ADMINISTRATION
AN ASSIGNMENT ON INCIDENT
REPORT AND ANECDOTAL REPORT
INTRODUCTION
An anecdotal record is an observation that is written like a short story. They are descriptions of incidents or events that are important to the person observing. Anecdotal records are short, objective and as accurate as possible DEFINITION Anecdotal records is a record of some significant item of conduct, a record of an episode in the life of students, a word picture of the student in action, a word snapshot at the moment of the incident, any narration of events in which may be significant about his personality. -Randall Meaning
- Informal device used by the teacher to record behavior of students as observed by him from time to time.
- It provides a lasting record of behavior which may be useful later in contributing to a judgment about a student. CHARACTERISTICS OF ANECDOTAL RECORDS Anecdotal records must possess certain characteristics as given below-
- They should contain a factual-descriptions of what happened, when it happened, and under what circumstances the behavior occurred.
- The interpretations and recommended action should be noted separately from the description.
- Each anecdotal record should contain a record of a single incident.
- The incident recorded should be that is considered to be significant to the students growth and development of example.
- Simple reports of behavior
- Result of direct observation.
- Accurate and specific
Include the responses of other people if they relate to the action. Describe the event in the sequence that it occurred. Record should be complete. They should be compiled and filed. They should be emphasized as an educational resource. The teacher should have practice and training in making observations and writing records. ITEMS IN ANECDOTAL RECORDS To relate the incident correctly for drawing inferences the following items to be incorporated:
- The first part of an anecdotal record should be factual, simple and clear.
- Name of the students
- Unit/ ward/ department
- Date and time
- Brief report of what happened.
- The second part of an anecdotal record may include additional comments, analysis and conclusions based on interpretations and judgments. ADVANTAGES OF ANECDOTAL RECORDS Supplements and validates of other structured instruments. i. Provision of insight into total behavioral incidents. ii. Needs no special training. iii. Use of formative feedback. iv. Economical and easy to develop. v. Open ended and can catch unexpected events. vi. Can select behaviors' or events of interest and ignore others, or can sample a wide range of behaviors' (different times, environments and people).
DISADVANTAGES OF ANECDOTAL RECORDS
A. If carelessly recorded, the purpose will not be fulfilled. B. Only records events of interest to the person doing the observing. C. Quality of the record depends on the memory of the person doing the observing. D. Incidents can be taken out of context. E. Subjectivity. F. Lack of standardization. G. Difficulty in scoring. H. Time consuming. I. May miss out on recording specific types of behaviour. J. Limited application. USES OF ANECDOTAL RECORDS Record unusual events, such as accidents. Record children's behavior, skills and interests for planning purposes. Record how an individual is progressing in a specific area of development. It provides a means of communication between the members of the health care team and facilitates coordinated planning and continuity of care. It acts as a medium for data exchange between the health care team. Clear, complete, accurate and factual documentation provides a reliable, permanent record of patient care.
ANNECDOTAL RECORD FORM
event that occurs at the facility, such as an injury to a patient. The purpose of the incident report is to document the exact details of the occurrence while they are fresh in the minds of those who witnessed the event. This information may be useful in the future when dealing with liability issues stemming from the incident. 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. Most incident reports that are written involve accidents with patients, such as patient falls. But most facilities will also document an incident in which a staff member or visitor is injured. A good incident report gives a thorough account of what happened without glossing over unsavory information or leaving out important facts. It is extremely important for the content of the Incident Report to reflect clear information in a factual, unbiased manner to avoid passing along opinions and judgments. DEFINITION Incident report is a written document describing in advertent trauma to a patient, errors or omissions in care, or untowardevents happening to staff or visitors. Such a report should be filed as soon after the event as possible it is also called as accident report. An incident report is a form that filled up in order to record the details of accidents, patient injury and other unusual events that occur in a health care facility such as a hospital or nursing home. It is also called an accident report which documents the exact details of the accident or unusual event while the information is still fresh in the minds of those who witness the event.
PURPOSES
An incident report is not part of the patient’s chart, but it may be used later in litigation. A report has following main purposes:
It informs the administration of the incident so management can prevent similar incidents in the future.
It alerts administration and the facility’s insurance company to a potential claim and the need for investigation.
Incident Reports are used to communicate information to other people and to document significant events within individual records and as required by state standards.
People often use the information obtained from incident reports when formulating plans or profiles, to develop support strategies and when making decisions.
To document the exact detail of an accident or unusual incident that occurred in a health care institution.
To be used in the future when dealing with liability issues stemming from the incident.
To protect the nursing staff against unjust accusation.
To protect and safeguard the client in case of negligence on the part of the nurse.
Helps in the evaluation of nursing care to ensure safe care to all patients. PRINCIPLES Blake identified six principles related to incident reporting-
Each cause of incident reflects a management problem.
One can predict that sets of circumstances will produce incidents. These circumstances can be identified and controlled.
In any group or array, a relatively small number of items will tend to give rise to the largest proportion of results.
The purpose of incident investigation is to locate and define the operational errors that allow incidents to occur.
Event, Behaviors, or Actions: incidents that is unusual, contrary to agency policy or procedure or which may result in injury.
Medication reaction: reaction to any drug administered at or provided by health department.
Property damage or missing articles.
Administration of wrong medication or vaccine.
Improper administration of medication or vaccine. WHO SHOULD REPORT
Only people who witness the incident should fill out and sign the incident report.
Each witness should file a separate report.
Once the report is filed, the nursing supervisor, department heads, administration, the facility’s attorney, and the insurance company may review it.
Because incident reports will be read by many people and may even turn up in court, one must follow strict guidelines when completing them.
If an incident report form does not leave enough space to fully describe an incident, attach an additional page of comments.
Document the incident as it occurred in the patient’s medical record. EMPLOYEE AND SUPERVISORY RESPONSIBILITY WHILE REPORTING THE INCIDENCE A. Employee Responsibility
All employees are responsible for preparing an incident report as soon as possible and reporting immediately to their supervisor or in the supervisors absence report to the administration any incident or injury including near misses.
Recommendations and appropriate changes shall be discussed with the supervisor and necessary corrections implemented to prevent further accidents.
B. Supervisor Responsibility
- Upon receiving a report of an incident, written or oral, the supervisor shall conduct an investigation.
- Following the investigation, supervisors are to review and complete the Incident Report.
- The supervisor shall take action to implement corrective measures immediately when the investigation reveals such actions are necessary.
- The supervisor shall provide a copy of the Incident Report Next Senior Officer within five working days of the accident.
- Reports of all incidents and near misses should be discussed during meetings with employees of the work unit to prevent problems of the same nature in the future. IMPORTANT ASPECTS TO BE FOLLOWED WHILE PREPARING INCIDENCE REPORT FOLLOWING THE PROTOCOL
a. Obtain the proper forms from the institution-
Each institution has a different protocol in place for dealing with an incident and filing a report.
Follow the instructions that accompany the forms.
Each organization uses a different format, so attention should be given to the guidelines.
In some cases nurse’s are responsible for filling out a form issued by the institution.
In other cases they are asked to type or write up the report on their own. b. Start the report as soon as possible-
Write it the same day as the incident if possible.
One should write down the basic facts that need to be remembered as soon as the incident occurs. c. Provide the basic facts-
If something untrue is written it may end up surfacing later, causing problems for the people involved in the incident.
Preserve the integrity of the institution you represent by telling the truth.
- POLISHING THE REPORT-
a. Double check the basic facts- - Check to make sure the basic information (spellings of names, the dates, times, and addresses, etc.). - Incident reports can appear later in a court of law. b. Edit and proof read the report-
- Read through it to make sure it's coherent and easy to understand.
- Make sure you didn't leave out any information that should have been included.
- Look for obvious gaps in the narrative that you might need to fill in.
- Check it one more time for spelling and grammar errors.
- Remove any words that could be seen as subjective or judgmental, like words describing feelings and emotions. c. Submit your incident report-
- Find out the name of the person or department to whom your report must be sent.
- When possible, submit an incident report in person and make yourself available to answer further questions or provide clarification.
- In situations where an incident report must be mailed or e-mailed, follow up with a phone call within a 10 day period to ensure that your report was received. TIPS FOR WRITING AN INCIDENT REPORT A. Write objectively: Record who and what applies Record details in objective terms
Describe what was seen and heard Describe only actions that were performed at the time of the event (e. assessment of injuries, assistance back to bed, physician present) B. Include essential information: Record where, when, and who applies Record what the patient said about the incident Record the time and place of incident Record physician contact C. Avoid opinions: Do not give your opinion on how it could have been avoided Speak to the nurse manager, supervisor, or risk manager D. Avoid the blame game: Do not use incident reports to blame others E. State only what happened: Avoid statements like, “Staffed below standard for unit” F. File report promptly and properly: Send to the designated department per organization policy RISK-REDUCTION RECOMMENDATIONS FOR NURSE MANAGERS
- Be sure that everyone is clear as to who is managing the patient. This is especially critical in complicated cases with numerous consults. One of the major factors in adverse events is fragmentation or lack of clear communication between providers. Therefore, use the medical record as a communication tool for all providers and encourage your staff to read notes from other providers and disciplines.
INCIDENT REPORT FORM
Hospital:
Patient Name: Age/ Sex: C. No: Ward: Bed: Date and Time of incident:
Nature of Incident: Medication Error
Cause of Incident: Wrong medication
Description of the Incident: .
Condition of patient after the incident:
Doctor’s Advice:
Signature of the doctor: Signature of the nurse:
Date of report:
BIBLIOGRAPHY
Basavanthappa BT, (2009), Nursing Education, New Delhi, Jaypee Brothers medical publishers. Vati, Joginder. Principles and Practice of Nursing Management and Administration. 1st edition, 2013, Jaypee Brothers Medical Publishers. 647- CV guide – Massachusetts Institute of Technology – Global Education & Career Development, United States Cover Letter guide – Massachusetts Institute of Technology – Global Education & Career Development, United State
Anecdotal AND Incident
Course: Nursing (01)
University: Kerala University of Health Sciences
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