If you work in human services-whether you are 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 isn't important only because of concerns about lawsuits. 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 assessed, 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 homicide, has steadily increased in recent years. These crimes are committed by patients, visitors, and other intruders to the institution.
When these incidents occur, the Joint Commission recommends a number of actions, including reporting violent activity or perceived threats as soon as possible, whether to facility administration or police. Proper documentation is crucial to ensure incidents are handled appropriately.
Like any skill, good documentation takes practice. Here are some pointers to make your task a little easier.
Know what to document. If you are not clear about what types of incidents require documentation, 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” of some kind.
Avoid delays. Incident reports should always be written as soon as possible after an incident occurs. Time quickly dims our memories. If you wait days-or even hours-before writing your report, you will begin to forget information that may be important. In addition, the accounts of others who were involved or who witnessed the incident can easily color your memory. After hearing such accounts, it becomes difficult to distinguish your own recollections from those of others. Without being aware of it, honest people will begin to change their stories, fill in gaps, and add extra bits of “post-incident information.”
Although it is important to provide emotional support to those who have been involved in a violent incident, try to minimize their conversations with others who were involved until all parties have been interviewed or have written an incident report.
List the basic facts of the incident chronologically. Answer the questions who, when, where, what, how, and why. Include events that led up to the incident. Describe all attempts to intervene-verbally or physically.
Be objective. Stick to the facts. Avoid commentary or subjective opinions. Make a distinction between personal knowledge and what you have learned from others. Do not try to blame or protect other people. Avoid labeling a person's mental or emotional state. For example, if you believe that an individual involved in an incident was intoxicated, describe the behavior or other signs that led you to that conclusion, rather than simply labeling the person as “drunk.”
Be accurate, concise, and clear. Be as brief as possible, but include necessary information. Double-check names, addresses, dates, and times. Check your grammar, spelling, and punctuation. Always do a rough draft, review it, and then prepare your final report.
After a crisis, it is critical to assess what has taken place and look for ways to prevent or minimize future occurrences. Your well-written incident report is an important tool in this process and a way to improve the safety of everyone who may be involved in crisis moments.