What should the nurse include in documentation after Mr. Lyles falls?

The rationale for including the completion of an incident report for risk management in documentation after a patient fall is that this report serves as a critical tool for identifying patterns, mitigating future risks, and improving patient safety within the healthcare facility. Incident reports are designed to document the circumstances surrounding an event, including what happened, when it occurred, and the actions taken in response. This thorough documentation can provide valuable insights for hospital administrators and quality assurance teams to devise strategies aimed at preventing similar incidents in the future.

Comprehensive incident reporting is not only a mandatory practice in many healthcare settings but also contributes to building a culture of safety and accountability. It ensures that all relevant details of the incident are captured, which can be crucial for both legal and clinical responses. This kind of systematic reporting is typically part of a facility’s risk management strategy aimed at minimizing liability and enhancing the safety and quality of patient care.

While informing shift staff, charting vital signs, or notifying the family are important actions in the context of patient care, they do not fulfill the same comprehensive need for formalized risk management documentation that the incident report does.