Whenever a patient complains, a doctor in our hospital makes a note in the chart ordering the nurse on duty to file an incident report. Normally, we'd only file an incident report for a specific problem, like a missed medication or a patient fall, and it wouldn't be included in the patient's chart. We nurses feel the physician's actions could get us into legal trouble. What do you say?

An incident report shouldn't be documented in a patient's medical record; it's an internal quality document used to report a clinical occurrence outside the normal course of the delivery of care. Incident reports are supposed to help organizations determine what caused an error and correct it, and shouldn't be used to blame individual clinicians for medical errors. If the chart shows an incident report exists, the patient may be able to use the document against the hospital in a legal proceeding. Patient complaints don't usually warrant the level of scrutiny given to an incident report, so the physician's behavior puts your hospital at legal risk. Report it to your medical director or chief medical officer, and handle patient complaints through your organization's official complaint process.

KAREN H. GELLER, RN, JD

The views and opinions expressed by RN's consulting attorneys are for general educational purposes and are not intended to take the place of specific legal advice, for which readers need to consult a personal attorney.