When documenting an incident in the nurse's notes, what should the nurse include? (Select all that apply.)
A) Description of injury, including diagrams of injury placement
B) Date, time, and location of incident
C) Name of physician and family members notified
D) Chronologic order of events of the incident
E) Confirmation that an incident report was initiated

Question

Quizplus · Accepted Answer

The documentation of the initiation of an incident report should not be included in the nurse's notes. Nurse's notes are part of the legal medical record; the incident report is not. To note that an incident report was initiated is a red flag that a problem has occurred.

When Documenting an Incident in the Nurse's Notes, What Should