Skilled Nursing Facilities

Create a New Incident Report

When creating a new incident record, you are guided through the documentation process with the Incident Documentation Wizard using the following menu tabs: Details, Injuries, Factors, Witnesses, Action, Notes and Signatures.

  1. Facility > Clinical > Risk Management > Active View > New.

  2. Enter Resident Name, Incident Date and Time, Type/Nature of incident, Incident Location), Person Preparing Report. Save.

  3. The incident Report Form appears with 7 tabs to direct you through completion of the report.

  4. Nursing Description – Enter descriptive details of the incident.

  5. Resident Description – Enter resident’s description of the incident if available. Select Resident Unable to give Description if applicable.

  6. Immediate Action Taken – Complete this field. Select Resident Taken to Hospital? if the resident was taken to the hospital due to this incident.

Details tab – Complete the fields in the Incident Description sections.

Injuries tab - The injuries tab is divided into two sections – Injuries Observed at Time of Incident and Injuries Reported Post Incident. Complete the fields in these sections as follows:

  1. Injuries Observed at Time of Incident – click New to open a pop-up with Type of Injury and Location of Injury lists. Complete those fields and click Save or Save and New if there are multiple injuries.

  2. Level of Pain – Select the time and then select which pain scale (either Numerical or PAINAD). Select pain level.

  3. Level of Consciousness and Mobility – Select the appropriate response for each from the lists.

  4. Mental Status – select the appropriate options.

  5. Notes – A text field for any additional notes regarding the resident’s injuries at the time of the incident.

  6. Injuries Report Post Incident – If further injuries occur or are found post incident, complete this section of the report as described above.

Factors tab – Use this tab to enter any predisposing information. The tab is divided into four sections: Environmental, Physiological, Situation, and Other Information. Complete this section by checking the appropriate check boxes and entering text as applicable in the ‘Other Information’ text box.

Witnesses tab – This tab is only available if Was the incident witnessed? is selected. After checking the box, a New button becomes available to record witnesses to the incident. Complete as follows:

  1. Click New. An Incident Witness pop-up appears. Enter the following details.

  2. Relation (list) - Select the relation of the witness to the resident. Use Staff if the witness has PointClickCare user access. Use Ancillary Staff for a witness without PointClickCare access such as housekeeping or maintenance staff.

  3. Name – If the incident was anyone other than staff with PointClickCare access, enter the name of the witness in the text box. If Staff is selected as a relation, select a name from a list of staff.

  4. Position – This field is only available if Staff is selected in the Relation list. Select the appropriate staff position.

  5. Date – Select the date of the witness statement using the calendar icon calendar.gif.

  6. Who Took Statement? – Select the staff member who took the statement by clicking the search icon lookup.gif.

  7. Statement – Type the witness statement in the text box provided.

  8. Phone Number 1-3 – Enter up to three phone number where the witness can be reached.

  9. Click Save or Save and New to continue entering witnesses.

  10. After entering witness details, click the Save to continue entering the incident. Or, click any of the other tabs of the incident record and the information is saved before moving to the selected tab.

Action tab – This tab is divided into four sections: Agencies/People Notified, Progress Notes, Triggered UDAs, and Care Plan. Complete as follows:

Agencies/People Notified – Click New to create a new entry. Complete as follows:

  1. In the Agency/Person Notified pop-up, select the Agency/Person from the list.

  2. If Physician is selected, enter the name and click the search icon lookup.gif. For any other option, enter the name in the field provided.

  3. Click Save to return to the incident or click Save and New to continue entering agency or persons notified.

  4. Progress Notes – IMPORTANT: If you write a progress note from within the incident record, the progress note appears in the progress notes section of the resident record.

    Note

    From within the Progress Note tab of the chart, with appropriate security, a link is available to bring you back to the Details tab of the Incident Report.

     Complete as follows:

    1. Click New to create a new progress note. The New Progress Note pop-up window appears.

    2. Select the appropriate type of progress note and complete the fields as with any other progress note.

    3. After the note is Saved/Signed, it appears in the Progress Notes tab of the resident record.

  5. To view a progress note previously created, click the View link next to the appropriate entry.

Triggered UDAs - Any User Defined Assessment (UDA) schedules triggered that were configured by incident type appear in this section. Complete as follows:

  1. Click the new link to create the triggered assessment -OR- Click the clear link to clear the triggered UDA schedules. This indicates the user has opted not to complete the triggered UDA.

  2. Click the edit link to continue with a triggered assessment already started. The assessment header contains the incident number which links to provide a jump to the incident record.

  3. After an assessment is complete, a view link appears next to the assessment. Click the link to view the assessment.

Care Plan - The three options available are to simply document on the incident what Care Plan action(s) are taken. There are no triggers from these actions. Check any/all that apply:

  1. Check Care Plan Reviewed if a care plan review was necessary and it is complete.

  2. Check Unusual Occurrence Report if an unusual occurrence report was required and it is complete.

  3. Check Care Conference Required if a care conference is needed or requested and the care conference date field appears to be entered.

  4. Click Save or Save & Next to continue entering the Incident. Alternatively, click any tabs of the incident record and it auto-saves.

Notes tab - Notes created in this tab are kept separate from the resident’s chart and can only be viewed from within the associated Incident record. To create a note:

  1. Click New. The New Note pop up appears.

  2. Complete the following fields:

    1. Enter the Effective Date using the calendar icon calendar.gif.

    2. Enter Note text in the field provided. Use the spellchecker abc icon to review and edit the text.

  3. To view/modify a note previously entered, with appropriate security access, click the edit link next to the appropriate entry.

  4. To delete a note from the list, with appropriate security access, click the del link next to the appropriate entry.

  5. Click Next.

Signatures tab - Each facility can define the positions in Clinical Setup that are required to sign as having reviewed incident records. Complete as follows:

  1. Click the sign link next to the appropriate position. The users name and date auto-populates in the corresponding fields.

  2. To reopen a signature, simply click un-sign. The user name and date are removed.

After all positions are signed, Lock becomes available. Click Lock to complete the incident report. The system returns to the Active View of the Risk Management Portal. After the report is locked, the incident report appears in the Historical View of the Risk Management portal.