The patient was in bed with all side rails up.During the night,the patient tried to get up to go to the bathroom and fell while trying to climb over the side rails.After meeting the patient's needs and assessing that the patient was not harmed,what step should the nurse take (if any) ?

A) Complete an incident report and put it in the medical record.
B) Chart what happened and state that an incident report has been filled out.
C) Do nothing because the patient was not harmed.
D) Document what happened in the patient record without mentioning the incident report.

Question

Jeffrey Nalesnik · Accepted Answer

Final Answer : D, Explanation :  Document in the patient's record an objective description of what you observed and follow-up actions taken without reference to the incident report.Incident reports are not a part of the permanent medical record but are an important source of risk-management data for identifying and addressing the causes of errors made in health care organizations.You complete the report even if an injury does not occur or is not apparent.

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