A nurse completes an incident report after a patient sustains a minor injury on the ward. Which documentation practice is correct?
Correct answer: A. Record objective facts and the actions taken
- A. Record objective facts and the actions taken
- B. Write personal opinions about who caused the event
- C. Copy the incident report into the medical record
- D. Leave the report unsigned to protect confidentiality
Explanation
An incident report should contain objective facts, relevant observations, witnesses and actions taken, without blame or speculation. It is a risk-management document and should not be copied into the patient's clinical record.
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About Ward and Unit Management
Ward management covers staffing and duty rosters, patient admission, discharge and transfer, delegation, supplies, equipment, records, reporting and coordination with the healthcare team. It also addresses bed management, infection prevention, emergency organisation and the difference between routine unit administration and direct nursing care.
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