file an incident report and document the finding in the client’s medical record
document the finding in the client’s medical record only
report the incident to the nursing supervisor
file an incident report but do not document the finding in the client’s medical record
Number 1 is correct.
Both an incident report and documentation of the finding in the client’s medical record should occur. The incident report is an internal communication mechanism meant for performance and quality improvement. Reporting the incident to the nursing supervisor fails to adequately communicate a medication administration error. Filing an incident report addresses internal notification of a potential area for improvement yet fails to document a potential problem in the client’s medical record.
