How to write a medical incident report

Written by simone watts
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How to write a medical incident report
You should write a medical incident report immediately after an incident. (Jupiterimages/Comstock/Getty Images)

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.

Skill level:

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  1. 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 computerised record keeping system.

  2. 2

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

  3. 3

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

  4. 4

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

  5. 5

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

  6. 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.

Tips and warnings

  • Do not make copies of the incident report. The document is considered confidential in some states.

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