How to Write a Medical Incident Report

Writing a medical incident report after any significant health-related incident is imperative. Incident reports provide doctors and other specialists with information about the patient and the incident, allowing them to better assess a patient's diagnosis, treatment plan and prognosis. Medical incident reports must be completed by the person who witnessed, first discovered or is most familiar with the incident.

Instructions

• 1

  Write the medical incident report immediately following the incident. This ensures you don't forget key details. Use a black ink pen to fill out an incident report form, or type it out if your employer uses a computerized record keeping system.

• 2

  Provide a brief description of the incident, using fact-based language. Never use subjective or opinionated language.

• 3

  Use quotes where applicable. Recall statements from patients or others involved in the incident.

• 4

  Record the names of any additional witnesses present during the incident.

• 5

  Document all findings in the incident report after the patient has been examined.

• 6

  Present the incident report to a direct supervisor or administrator. Do not file the incident report in the patient's medical chart. An incident report is an administrative document and should be given to the proper authorities.