Submitting Incident Reports
When something unusual or concerning happens during a visit, document it properly with an incident report. Timely, accurate reporting protects everyone and ensures appropriate follow-up.
What Is an Incident
An incident is any event that:
- Is out of the ordinary
- Could harm the client or others
- Needs to be documented formally
- Requires management attention
- May need follow-up action
Types of Incidents to Report
Always Report
- Falls - Even if no injury
- Injuries - Any harm to client
- Medical emergencies - 911 calls, sudden illness
- Behavioral episodes - Aggression, self-harm threats
- Missing person - Client left without notice
- Abuse/neglect - Suspected or witnessed
- Property damage - Significant damage
- Medication errors - Wrong dose, missed, wrong time
May Need Reporting
- Unusual behavior
- Changes in condition
- Client complaints
- Safety concerns
- Equipment problems
- Environmental hazards
When in doubt, report it.
When to Report
Immediately
Some incidents require immediate action:
- Ensure client safety first
- Call 911 if emergency
- Contact supervisor
- Then document
Same Day
Most incidents should be reported:
- As soon as practical
- Same day required
- Within hours if possible
- Before you forget details
Don't Delay
Late reporting causes problems:
- Details are forgotten
- Response is delayed
- Compliance issues
- Investigation difficulties
Submitting an Incident Report
Step by Step
- Go to Documentation or Incidents
- Tap Report Incident or New Incident
- Select the incident type
- Fill in required details
- Add any photos or evidence
- Submit the report
Required Information
Provide complete details:
- Date and time - When did it happen?
- Location - Where exactly?
- Who was involved - Client, others present
- What happened - Detailed description
- Immediate actions - What did you do?
- Witnesses - Who else saw it?
- Injuries - Any harm sustained?
Detailed Description
Write a clear narrative:
- Start with what you observed
- Include exact times if known
- Note what led up to the incident
- Describe the incident itself
- Document your response
- Include client's statements
- Note the outcome
Example:
"At approximately 2:15 PM, while I was assisting client with transfer from bed to wheelchair, client's left foot caught on bedframe. Client lost balance and fell to floor, landing on right hip. I immediately checked for injury - client reported pain in right hip but no visible injury. I called supervisor and followed fall protocol. EMTs arrived at 2:45 PM and transported to hospital for evaluation."
Documentation Guidelines
Be Factual
Write what you observed:
- Stick to facts
- Avoid assumptions
- Don't assign blame
- Report what happened
Good: "Client stated 'I haven't eaten in three days.'"
Poor: "Client's family is neglecting them."
Be Specific
Include details:
- Exact times
- Specific locations
- Direct quotes
- Measurable observations
Be Objective
Use neutral language:
- No opinions
- No judgments
- Report observations
- Let facts speak
Be Thorough
Don't leave gaps:
- Complete all fields
- Answer all questions
- Include relevant context
- Note what you don't know
Attaching Evidence
Photos
When appropriate:
- Photo of injury (with consent)
- Environmental hazard
- Property damage
- Scene documentation
Tips for Photos
- Clear and focused
- Good lighting
- Multiple angles if needed
- Date/time stamped
Other Evidence
You may also attach:
- Documents
- Screenshots
- Additional notes
- Related records
After Submitting
What Happens Next
- Report goes to supervisor
- They review and may contact you
- Follow-up actions assigned
- Investigation if needed
- Report closed with resolution
Your Role After
- Be available for questions
- Provide additional information if needed
- Follow any instructions given
- Continue monitoring situation
Notification
You may be notified about:
- Receipt of your report
- Status updates
- Investigation findings
- Resolution
Follow-Up Requirements
Mandatory Reporting
Some incidents require external reporting:
- Suspected abuse/neglect → Adult Protective Services
- Certain injuries → State agencies
- Deaths → Various authorities
Your administrator handles external reports, but you may be involved.
Internal Follow-Up
You may need to:
- Complete additional forms
- Participate in review
- Implement new procedures
- Attend training
Incident Categories
Falls
Document:
- What caused the fall
- Surface landed on
- Any injuries
- Ambulatory aids in use
- Environmental factors
Medical Emergencies
Document:
- Symptoms observed
- Vital signs if taken
- 911 response time
- Hospital transported to
- Family notification
Behavioral Incidents
Document:
- Triggers if known
- Behaviors observed
- Duration
- Your response
- Outcome
Property Damage
Document:
- What was damaged
- How it happened
- Estimated value
- Photos
- Who was notified
Common Mistakes
Waiting Too Long
Don't delay - memories fade and details get lost.
Not Enough Detail
"Client fell" is not sufficient. Include when, where, how, injuries, response.
Being Judgmental
Don't write "client was careless." Write what happened factually.
Forgetting to Submit
A saved draft isn't submitted. Complete and submit the report.
Not Following Up
Check that your report was received and processed.
Your Protection
Why Reporting Protects You
- Documents that you followed procedure
- Shows you responded appropriately
- Creates record of events
- Supports your account
Documentation Tips
- Report promptly
- Be thorough
- Keep copies if possible
- Note who you notified