Despite Its Dangers Experts Say Football Is Safer Than Ever How to Document Any Incident

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How to Document Any Incident

If you work in human services—whether you’re a social worker, health care professional, child care worker, or any other human service provider—you probably know that good documentation is an important part of your job. Documentation is important not only because of litigation concerns. Good documentation provides a detailed account of an incident so that appropriate follow-up action is taken, patterns and trends are identified, policies and procedures can be evaluated, and steps can be taken to improve the safety of everyone in your facility.

According to a Sentinel Alert issued by the Joint Commission in 2010, the number of violent incidents in health care settings, some as serious as assault, rape and murder, has risen steadily in recent years. These crimes are committed by patients, visitors and other intruders in the institution.

When these incidents occur, The Joint Commission recommends several actions, including reporting violent activity or perceived threats as soon as possible, whether to facility management or the police. Proper documentation is critical to ensure incidents are handled appropriately.

As with any skill, good documentation takes practice. Here are some pointers to make your task a little easier.

Know what to document. If it’s not clear what types of incidents you need documentation for, check your policies and procedures or ask your supervisor. Make sure you know which situations require a full incident report and which require only “charting” or “logging.”

Avoid procrastination. Incident reports should always be written as soon as possible after an incident occurs. Time quickly erodes our memories. If you wait days—or hours—before writing your report, you’ll start to forget important information. Additionally, the accounts of others who were involved or who witnessed the event can easily color your memory. After hearing such accounts, it becomes difficult to distinguish our own memories from those of others. Without realizing it, honest people will start changing their stories, filling in blanks and adding extra bits of “information after the fact.”

While it is important to provide emotional support to those involved in a violent incident, try to minimize conversations with others involved until all parties have been interviewed or an incident report has been written.

List the basic facts of the incident in chronological order. Answer the questions who, when, where, what, how and why. Include the events that happened. Describe all attempts to interfere – verbally or physically.

Be objective. Stick to the facts. Avoid comments or subjective opinions. Distinguish between personal knowledge and what you have learned from others. Don’t try to blame or protect other people. Avoid labeling a person’s mental or emotional state. For example, if you believe someone involved in an incident was drunk, instead of labeling the person “drunk,” describe the behavior or other symptoms that led you to that conclusion.

Be precise, concise and clear. Be as brief as possible, but include essential information. Double check names, addresses, dates and times. Check your grammar, spelling and punctuation. Always prepare a rough draft, review it and then prepare your final report.

After a crisis, it is important to assess what happened and find ways to prevent or reduce future incidents. Your written incident report is an important tool in this process and a way to improve the safety of everyone involved in moments of crisis.

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