DOCUMENTATION
GUIDELINES
FOR SCSB QUALITY REPORTING STANDARDS
DEFINITIONS
• Incident – any event that affects an individual’s safety.
• Medical Incident – an incident that occurs involving an
individual which requires the implementation of first aid
training by staff, the immediate care of a medical
professional, or has the potential to cause medical care in
the near future and requires monitoring by staff.
• Behavioral Incident – an incident in which an individual
becomes physically aggressive toward staff or other
individuals or threatens another individual while having
the ability to carry out the threat.
BLAME-FREE ENVIRONMENT
Southside Community Services supports
a “Blame-Free” Environment:
• Employees are mandated to report all
incidents, accidents or occurrences.
• By getting to the root cause of an error, we
can correct the underlying issue that allowed
the event to occur; this is the process of
learning.
INCIDENT/ACCIDENT REPORTS
• An incident/accident report should be completed in
Credible whenever an event occurs.
Examples:
 Accident (vehicular/nonvehicular)
 Allegation of Abuse/Neglect
 Arrested/Detained
 Assault of or by an individual
 Choking
 Fall (including the result of
seizure)
 Fire
 Injury (minor)
 Medical Emergency
 Medication Errors
 Missing Individual
 Property Damage/Destruction









Self-Injury (without suicidal intent)
Seizure
Suicidal (thoughts, gestures, attempts)
Sexual Incident (allegations, suspicion,
observation of harassment, rape, or
inappropriate contact/behavior)
Theft (agency property)
Theft (individual’s property)
Threatening Behavior (verbal threats,
intimidation, threatening gesture,
inappropriate contact)
Violent Behavior
Other
WHEN SHOULD INCIDENTS BE
REPORTED?
• Anytime an incident occurs in which an individual could
have been injured OR whenever there is a deviation from
established policy and procedures.
• Once the immediate medical needs of the individual are
met and the situation is under control.
• Employees are required to report the incident as soon as possible.
• As soon as possible after the incident has occurred.
• People forget 50-80% of what they’ve witnessed after one day and
97% after one month (1).
WHY FILE AN INCIDENT REPORT?
• Southside Community Services is mandated by DBHDS to file
incident reports in a timely manner.
• It’s a way for Administration/QA to track emerging trends
and to prevent a recurrence of an incident.
• Some incidents can result in lawsuits.
• If a claim were filed and the case proceeded to court, which could be
years after the event, you or anyone else involved might be hardpressed to recreate the scene.
ENTERING INCIDENT
REPORTS
INTO CREDIBLE
Examples of Location:





Bedroom
Classroom
Bathroom
Dining Room
Parking Lot
List the people involved in, or who observed, the
incident/accident. Ensure that you include the following: Name |
Title | Role (e.g. client, staff, visitor, witness…etc.) | Contact
Information (e.g. address, worksite, phone #, email..etc.)
Betty Rose – Quality Control Specialist – Staff
143 Industrial Parkway
Clarksville, VA 23927
1-434-579-6916
brose@sscsb.org
Teresa Park – QA Trainer – Staff/Witness
143 Industrial Parkway
Clarksville, VA 23927
1-434-579-6916
tpark@sscsb.org
Elvis Presley – Client
100 My Home Avenue
South Boston, VA 24592
1-434-000-0000
Describe the incident/accident in detail, including circumstances prior
to the incident/accident as well as the conditions at the time of the
incident/accident. Be sure to include a thorough description of any
injuries and/or property damage.*
ABC

+
 Spell check
 Box Adjust
(1) WHO was involved in the incident?
(4) WHERE did the incident occur?
(2) WHAT happened?
(5) WHY did the incident occur?
(3) WHEN did the incident occur?
(6) HOW was the incident handled?
Describe immediate actions taken. Include the names of
individuals to whom the incident/accident was reported as well as
the name of the individual who made the report. Include
applicable dates and times.*
ABC

+
Please include the following:
 What actions did you take?
 Was First Aid admistered?
 Did you check vital signs?
 At what time did you notify:
 Your Immediate Supervisor
 Your Program Director
 The Individual’s Primary Care
Physician
 911
 A/R or Guardian
 Arrival & Departure time of EMS
 What facility was
individual taken to?
 Arrival time of A/R or Guardian:
 To the E.R., Physician’s
Office, or to the program.
Performed
by
SCS Staff
The Date of Report should be the day that
you enter the incident into CREDIBLE.
WHO TO NOTIFY FOR AN EMERGENCY
INCIDENT?
Staff may notify the
A/R or Guardian
during:
 After hours
 Weekends
 If directed by
Supervisor
* Never leave an
individual alone
during an emergency!
WHO TO NOTIFY FOR A NONEMERGENCY INCIDENT?
Staff may notify the
A/R or Guardian
during:
 After hours
 Weekends
 If directed by
Supervisor
GUIDELINES FOR QUALITY
REPORTING
Regardless of the charting method used, documentation must be:
•Objective- Perform assessments using your senses of touch, sight,
hearing, and smell, and document facts.
•Avoid general statements.
•Free of grammatical/spelling errors
•Must be completed in a timely manner.
•Should include names of all individuals notified/involved, and steps
taken.
•ACCURATE Chronological order (DATE &TIME)
•Abbreviations are to be avoided.
•With Dignity and Respect utilized at all times.
EXAMPLES OF QUALITY REPORTING
Be Precise:
Accurately reporting sequences of events will protect you from scrutiny.
Poor Example: “Individual fell in the smoking area. Cut his knee, it
was cleaned and covered with a piece of gauze. Reported to Jane.”
Quality Example: "Individual fell on deck of HDTC smoking area at
0900. He received a 1/2” laceration to his left knee, no other injuries
noted, no complaints of pain. BP- 128/74, Pulse -92 , Resp.-22.
Individual was able to stand and walk into building without assistance
and without difficulty. Area on left knee was cleaned with soap and
water using Universal Precautions and Covered with a sterile gauze
pad, and held in place with paper tape. Jane Smith, Supervisor was
notified of injury to left knee and of treatment provided at 0915. J.
Smith, Supervisor advised she will notify the individual’s guardian of
injury as well as individual’s physician for further directions.
EXAMPLES OF QUALITY REPORTING
• Be Objective
• Always try to remove personal emotions and opinions
from the writing you do. Do not document your feelings,
hunches, or viewpoints.
• Example: “Patient acting crazy.”
This statement relies on staff’s subjective opinion of the
individual’s mental state. A better version would be:
“Individual pacing back and forth, breathing fast,
clenching fists, yelling ‘Don’t touch me!’ repeatedly.”
• This provides a clear picture of what actually happened
during the incident, allowing the reader to see a clear
picture of the individuals actions.
EXAMPLES OF QUALITY REPORTING
• Record all communication with others.
• Your communications with the individual’s ,
Therapists, Case Manager, Nurse, Physician,
Psychiatrist, and/or their AR/Guardian regarding
any changes in their physical or behavioral health
should be documented, especially if it is in
reference to the care of the individual. Recording
of this communication allows a reader to track
changes and establish clear lines of cause and
effect. Be sure to indicate the time contact was
made and information that was given.
EXAMPLES OF QUALITY REPORTING
When providing care to individuals, remember that it
is important to:
• Follow SCS Board Policy and Procedures.
• Standards as trained in; AHA Firstaid/CPR/AED.
• The Mandt System
• Medication Training
ENTERING PEER-TO-PEER
INCIDENT REPORTS
INTO CREDIBLE
WHO
was involved in the
incident?
WHAT
happened?
WHEN
did the incident
occur?
WHERE
did the incident
occur?
WHY
did the incident
occur?
HOW
was the incident
handled?
PEER-TO-PEER INCIDENTS
• When a Peer-to-Peer Incident occurs, staff must report the
following in CREDIBLE:
1) Incident/Accident Report
2) Peer-to-Peer Incident Report
• If the incident involved (2) or more individuals, staff shall
complete an Incident/Accident/P2P report for EACH of the
individual’s involved.
• Document the MANDT techniques that were used to alleviate
the incident.
• Removal of stimulus, offer options, least amount of interaction
necessary for safety, structured cooling off, active listening.
Give description of techniques used.
ENTERING SERIOUS INJURY
INCIDENT REPORTS
INTO CREDIBLE
SERIOUS INJURY REPORTS
• Serious Injury - any injury that requires medical attention by a licensed
professional.
• When a Serious Injury Incident occurs, staff must report the following in
CREDIBLE:
1)
2)
3)
4)
Incident/Accident Report
Complete for All Incident Report
Serious Injury Report
Peer-to-Peer Incident Report  IF APPLICABLE
• Examples:
• Serious physical injury
• Loss of consciousness
• Attempted suicides
• Medication overdoses
• Reactions from medications
administered or prescribed
* Complete these (2) forms
whenever an individual requires
medical attention from a licensed
professional.
ENTERING DEATH REPORTS
INTO CREDIBLE
* Complete these (2) forms
whenever a death occurs to an
individual that is or has received
services in an SCS program.
Be sure to include:
Date of Death
Time of Death
Date of Discovery
Location
How you were
informed?
 Was the individual
death referred to a
medical examiner?





ENTERING MEDICAL
ERRORS
INTO CREDIBLE
WHEN TO REPORT A MEDICATION
ERROR?
Document in Credible when the following occurs:
• Medication Error
• Medication Discrepancy
• Medication Count Discrepancy
• Medication Reaction
• Pharmacy Discrepancy
• Failure of staff to document on the MAR at the actual time
the medication/treatment was actually dispensed or
omission of medication.
DOCUMENTATION REQUIRED
(1)
Staff Completes
(2)
Staff Completes
(3)
Supervisor
Completes
* All three options must be completed.
DOCUMENTATION TIPS
• Be Exact. Describe exactly what your involvement was. How were
you involved? Example: If you didn’t see the individual fall,
document that you found the individual lying on the floor.
• Be Clear. Someone should be able to read your documentation
and know exactly what happened, regardless of their background.
• Write Objectively. Describe what you heard, what you saw,
smelled, touched. Paint a clear picture.
• Add Direct Quotes. State the individual’s comments as direct
quotes. For example: The individual stated, “I do not feel good and
I’m feeling dizzy”.
• Be grammatically correct. You are not the only person that sees
these reports; be as professional as you can. Remember, these
reports are legal documents and can be used in legal proceedings
or investigations.
QUESTIONS?