NIGHTINGALE INSTITUTE OF

NURSING, NOIDA

ASSIGNMENT
ON
ANECDOTAL RECORDS ,
INCIDENT REPORTS
(SUBJECT: NURSING MANAGEMENT)

SUBMITTED TO SUBMITTED BY
Ms. ANN GLADIS Ms. DHAIRYA ARORA
ASSOCIATE PROFESSOR M. Sc.(N) 2nd YEAR
NIN, NOIDA NIN, NOIDA
INTRODUCTION
An anecdotal record is an observation that is written like a short story. They are descriptions of
incidents or events that are important to the person observing. Anecdotal records are short,
objective and as accurate as possible

DEFINITION
Anecdotal records is a record of some significant item of conduct, a record of an episode in the
life of students, a word picture of the student in action, a word snapshot at the moment of the
incident, any narration of events in which may be significant about his personality.
-Randall
Meaning
• Informal device used by the teacher to record behavior of students as observed by him from
time to time.
• It provides a lasting record of behavior which may be useful later in contributing to a judgment
about a student.

CHARACTERISTICS OF ANECDOTAL RECORDS

Anecdotal records must possess certain characteristics as given below-
1. They should contain a factual-descriptions of what happened, when it happened, and under
what circumstances the behavior occurred.
2. The interpretations and recommended action should be noted separately from the description.
3. Each anecdotal record should contain a record of a single incident.
4. The incident recorded should be that is considered to be significant to the students growth
and development of example.
5. Simple reports of behavior
6. Result of direct observation.
7. Accurate and specific
8. Gives context of child's behavior
9. Records typical or unusual behaviors

PURPOSE
 To furnish the multiplicity of evidence needed for good cumulative record.
 To substitute for vague generalizations about students specific exact description of
behaviour.
 To stimulate teachers to look for information i.e pertinent in helping each student realize
good self- adjustment.
 To understand individual’s basic personality pattern and his reactions in different situations.
 The teacher is able to understand her pupil in a realistic manner.
 It provides an opportunity for healthy pupil- teacher relationship.
 It can be maintained in the areas of behaviour that cannot be evaluated by other systematic
method.
 Helps the students to improve their behavior, as it is a direct feedback of an entire observed
incident, the student can analyze his behaviour better.
 Can be used by students for self-appraisal and peer assessment.
GUIDELINES FOR MAKING ANECDOTAL RECORD
 Keep a notebook handy to make brief notes to remind you of incidents you wish to include in
the record. Also include the name, time and setting in your notes.

 Write the record as soon as possible after the event. The longer you leave it to write your
anecdotal record, the more subjective and vague the observation will become.

 In your anecdotal record identify the time, child, date and setting

 Describe the actions and what was said.

 Include the responses of other people if they relate to the action.

 Describe the event in the sequence that it occurred.

 Record should be complete.

 They should be compiled and filed.

 They should be emphasized as an educational resource.

 The teacher should have practice and training in making observations and writing records.

ITEMS IN ANECDOTAL RECORDS

To relate the incident correctly for drawing inferences the following items to be incorporated:
• The first part of an anecdotal record should be factual, simple and clear.
• Name of the students
• Unit/ ward/ department
• Date and time
• Brief report of what happened.
• The second part of an anecdotal record may include additional comments, analysis and
conclusions based on interpretations and judgments.

ADVANTAGES OF ANECDOTAL RECORDS

Supplements and validates of other structured instruments.
 i. Provision of insight into total behavioral incidents.
ii. Needs no special training.
iii. Use of formative feedback.
iv. Economical and easy to develop.
v. Open ended and can catch unexpected events.
vi. Can select behaviors' or events of interest and ignore others, or can sample a wide range
of behaviors' (different times, environments and people).

DISADVANTAGES OF ANECDOTAL RECORDS

A. If carelessly recorded, the purpose will not be fulfilled.
B. Only records events of interest to the person doing the observing.
C. Quality of the record depends on the memory of the person doing the observing.
D. Incidents can be taken out of context.
E. Subjectivity.
F. Lack of standardization.
G. Difficulty in scoring.
H. Time consuming.
I. May miss out on recording specific types of behaviour.
J. Limited application.

USES OF ANECDOTAL RECORDS

 Record unusual events, such as accidents.
 Record children's behavior, skills and interests for planning purposes.
 Record how an individual is progressing in a specific area of development.
 It provides a means of communication between the members of the health care team and
facilitates coordinated planning and continuity of care. It acts as a medium for data exchange
between the health care team.
 Clear, complete, accurate and factual documentation provides a reliable, permanent record
of patient care.
 ANNECDOTAL RECORD FORM

Student: Ms. Esther Age: 19 Years

Observer: Ms. Sunita Date: 21 January 2019; 11 am

Setting: Nightingale Institute of Nursing

Purpose: To observe the behaviour of student towards clients care.

Description of Incident:

Ms. Esther is a II year GNM student of Nightingale Institute College of Nursing. Her General
Appearance is good and came in neat uniform. She Is giving respect to the staffs. When she
assigned to do the nail care she prepared the tray well with all articles. She instructed patient
to regarding the nail cutting procedure. But she did not wash her hands before the procedure.
She has good knowledge regarding the care. After the procedure she recorded the procedure
in book and got sign in the record.

Notes/ Comments:

1. She can improve her promptness.

2. She can develop her skills in doing procedure.

3. She can improve her confidence in doing procedure.

Signature of the clinical instructor

 INCIDENT REPORT
INTRODUCTION
In a health care facility, such as a hospital, nursing home, or assisted living, an incident
report or accident report is a form that is filled out in order to record details of an unusual event
that occurs at the facility, such as an injury to a patient. The purpose of the incident report is
to document the exact details of the occurrence while they are fresh in the minds of those who
witnessed the event. This information may be useful in the future when dealing with liability
issues stemming from the incident. Generally, according to health care guidelines, the report
must be filled out as soon as possible following the incident (but after the situation has been
stabilized). This way, the details written in the report are as accurate as possible. Most incident
reports that are written involve accidents with patients, such as patient falls. But most facilities
will also document an incident in which a staff member or visitor is injured.
A good incident report gives a thorough account of what happened without glossing over
unsavory information or leaving out important facts. It is extremely important for the content of
the Incident Report to reflect clear information in a factual, unbiased manner to avoid passing
along opinions and judgments.

DEFINITION
Incident report is a written document describing in advertent trauma to a
patient, errors or omissions in care, or untowardevents happening to staff or visitors. 
Such a report should be filed as soon after the event as possible it is also called as accident
report.
An incident report is a form that filled up in order to record the details of accidents, patient injury
and other unusual events that occur in a health care facility such as a hospital or nursing home. It
is also called an accident report which documents the exact details of the accident or unusual
event while the information is still fresh in the minds of those who witness the event.

PURPOSES
 An incident report is not part of the patient’s chart, but it may be used later in litigation.
 A report has following main purposes:
1. It informs the administration of the incident so management can prevent similar incidents in
the future.
2. It alerts administration and the facility’s insurance company to a potential claim and the need
for investigation.
3. Incident Reports are used to communicate information to other people and to document
significant events within individual records and as required by state standards.
4. People often use the information obtained from incident reports when formulating plans or
profiles, to develop support strategies and when making decisions.
5. To document the exact detail of an accident or unusual incident that occurred in a health
care institution.
6. To be used in the future when dealing with liability issues stemming from the incident.
7. To protect the nursing staff against unjust accusation.
8. To protect and safeguard the client in case of negligence on the part of the nurse.
9. Helps in the evaluation of nursing care to ensure safe care to all patients.
PRINCIPLES
Blake identified six principles related to incident reporting-
1. Each cause of incident reflects a management problem.
2. One can predict that sets of circumstances will produce incidents. These circumstances can
be identified and controlled.
3. In any group or array, a relatively small number of items will tend to give rise to the largest
proportion of results.
4. The purpose of incident investigation is to locate and define the operational errors that allow
incidents to occur.
5. Accountability is the key to effective incident investigation and analysis.
6. The past performance of an organization or unit tends to forecast its future performance.
RISK MANAGEMENT & INCIDENT REPORTS
 Risk management is a process designed to prevent adverse consequences and minimize
adverse economic effects on an organization occasioned by accidental loss.
 The focus of risk management then is to prevent financial loss resulting from actual injury
to patients, visitors, employees and medical staff, as well as from damage, theft or loss of
property belonging to the healthcare organization.
 Risk management involves insuring against financial loss and developing a systematic
process to identify, evaluate, reduce or eliminate deviations from expected results.
 Over time, risk management has evolved to include evaluation and monitoring of clinical
practice to recognize and prevent patient injury.
 Incident reporting traditionally has involved documenting actual unexpected or unusual
events retrospectively (i.e., after the harmful event has transpired).
 Data from the incident reports are then tracked for quality assurance and risk management
purposes. Incident reports allow the detection of emerging trends or problems.
WHEN TO REPORT
 Incidents that must be reported and documented include:
1. Exposure Incidents: skin, eye, mucous membrane or parental contact with blood or other
potentially infectious materials that may result from the performance of an employee’s
duties.
2. Accident, Injury: patient, visitor, employee slips or falls, or other incident, which results or
may result in injury.
3. Event, Behaviors, or Actions: incidents that is unusual, contrary to agency policy or
procedure or which may result in injury.
4. Medication reaction: reaction to any drug administered at or provided by health department.
5. Property damage or missing articles.
6. Administration of wrong medication or vaccine.
7. Improper administration of medication or vaccine.
WHO SHOULD REPORT
1. Only people who witness the incident should fill out and sign the incident report.
2. Each witness should file a separate report.
3. Once the report is filed, the nursing supervisor, department heads, administration, the
facility’s attorney, and the insurance company may review it.
4. Because incident reports will be read by many people and may even turn up in court, one
must follow strict guidelines when completing them.
5. If an incident report form does not leave enough space to fully describe an incident, attach an
additional page of comments.
6. Document the incident as it occurred in the patient’s medical record.
EMPLOYEE AND SUPERVISORY RESPONSIBILITY WHILE REPORTING THE
INCIDENCE
A. Employee Responsibility
1. All employees are responsible for preparing an incident report as soon as possible and
reporting immediately to their supervisor or in the supervisors absence report to the
administration any incident or injury including near misses.
2. Recommendations and appropriate changes shall be discussed with the supervisor and
necessary corrections implemented to prevent further accidents.
B. Supervisor Responsibility
1. Upon receiving a report of an incident, written or oral, the supervisor shall conduct an
investigation.
2. Following the investigation, supervisors are to review and complete the Incident Report.
3. The supervisor shall take action to implement corrective measures immediately when the
investigation reveals such actions are necessary.
4. The supervisor shall provide a copy of the Incident Report Next Senior Officer within five
working days of the accident.
5. Reports of all incidents and near misses should be discussed during meetings with employees
of the work unit to prevent problems of the same nature in the future.
IMPORTANT ASPECTS TO BE FOLLOWED WHILE PREPARING INCIDENCE
REPORT
FOLLOWING THE PROTOCOL

a. Obtain the proper forms from the institution-

-  Each institution has a different protocol in place for dealing with an incident and filing a
report.
- Follow the instructions that accompany the forms.
- Each organization uses a different format, so attention should be given to the guidelines.
- In some cases nurse’s are responsible for filling out a form issued by the institution.
- In other cases they are asked to type or write up the report on their own.
b. Start the report as soon as possible-
- Write it the same day as the incident if possible.
- One should write down the basic facts that need to be remembered as soon as the incident
occurs.
c. Provide the basic facts-
- Start the report with a sentence clearly stating the following basic information.
- The time, date and location of the incident (be specific; write the exact address, etc.).
- Your name and ID number.
- Names of other members of the organization who were present.

DESCRIBING WHAT HAPPENED

a. Write a first person narrative telling what happened-
- Use the full names of each person included in the report.
- Answer who, what, when, where, and why of what happened.
- If possible, make sure to include direct quotes from witnesses and other people involved in
the incident
b. Be thorough-  
- Write as much as you can remember - the more details, the better.
- Don't worry about report being too long or wordy.
- The important thing is to report a complete picture of what occurred.
c. Be accurate-
- Do not write something in the report that you aren't sure actually happened.
- Additionally, if you are reporting what the witness told you, you should write down
anything that you remember about the witness's demeanor.
d. Be clear-  
- Don't use flowery, confusing language to describe what occurred.
- The writing should be clear and concise.
- Use short, to-the-point, fact-oriented sentences that don't leave room for interpretation.
e. Be honest-
- It's imperative that whatever is written it should be an honest account.
- If something untrue is written it may end up surfacing later, causing problems for the people
involved in the incident.
- Preserve the integrity of the institution you represent by telling the truth.
3. POLISHING THE REPORT-
a. Double check the basic facts-
-   Check to make sure the basic information (spellings of names, the dates, times, and
addresses, etc.).
- Incident reports can appear later in a court of law.
b. Edit and proof read the report-
- Read through it to make sure it's coherent and easy to understand.
- Make sure you didn't leave out any information that should have been included.
- Look for obvious gaps in the narrative that you might need to fill in.
- Check it one more time for spelling and grammar errors.
- Remove any words that could be seen as subjective or judgmental, like words
describing feelings and emotions.
c. Submit your incident report-  
- Find out the name of the person or department to whom your report must be sent.
- When possible, submit an incident report in person and make yourself available to
answer further questions or provide clarification.
- In situations where an incident report must be mailed or e-mailed, follow up with a
phone call within a 10 day period to ensure that your report was received.
TIPS FOR WRITING AN INCIDENT REPORT
A. Write objectively:
 Record who and what applies
 Record details in objective terms
 Describe what was seen and heard
  Describe only actions that were performed at the time of the event (e.g. assessment of
injuries, assistance back to bed, physician present)
B. Include essential information:
 Record where, when, and who applies
 Record what the patient said about the incident
 Record the time and place of incident
 Record physician contact
C. Avoid opinions:
 Do not give your opinion on how it could have been avoided
 Speak to the nurse manager, supervisor, or risk manager
D. Avoid the blame game:
 Do not use incident reports to blame others
E. State only what happened:
 Avoid statements like, “Staffed below standard for unit”
F. File report promptly and properly:
 Send to the designated department per organization policy
RISK-REDUCTION RECOMMENDATIONS FOR NURSE MANAGERS
1. Be sure that everyone is clear as to who is managing the patient. This is especially critical in
complicated cases with numerous consults. One of the major factors in adverse events is
fragmentation or lack of clear communication between providers. Therefore, use the medical
record as a communication tool for all providers and encourage your staff to read notes from
other providers and disciplines.
2. Be sure staff understand and utilize the chain of command when necessary. They are
considered patient advocates and must speak on behalf of the patient to ensure quality patient
care. Documentation of the chain of command process should be factual and blameless.
3. If an adverse event occurs, the staff must know that attention to patient needs is first and
foremost. If a patient is injured, nursing and medical interventions take precedence over
everything else.
4. Follow the organization’s policy on medical-event disclosure. It is important that staff
understand who is designated to inform the patient/family. Documentation should include who
was present during the discussion, what information was discussed, and all of the patient/family
responses.
5. Ensure that the patient/family receives compassionate care and that everyone involved
maintains a professional relationship.
6. If an adverse event occurs, contact the risk manager. Discuss the case discretely, because
conversations are not protected under a quality statute or attorney-client privilege, and therefore
may be discoverable
7. Work with the risk manager. The risk manager can help you and your staff promote patient
safety and proactive strategies to avoid injuries.
 INCIDENT REPORT FORM
Hospital: ESIC. Hospital

Patient Name: Mrs. Renu

Age/ Sex: 54 Years/ Female
C.R. No: 1100345
Ward: Medicine Ward
Bed: 32

Date and Time of incident: 18th Jan, 2019, 1 pm

Nature of Incident: Medication Error

Cause of Incident: Wrong medication

Description of the Incident:

Sister who was assigned for care to Mrs. Renu has given a Tab. Propranol instead of Tab
pantop by mistake as she was confused by trade name.

Condition of patient after the incident:

Patient became restlessness and while taking B.P it was rise than normal.

Doctor’s Advice: Patient was immediately stabilized, Vitals monitored, administered IV

fluids and shifted to ICU.
Signature of the doctor:
Signature of the nurse:

Date of report: 18/01/2019

BIBLIOGRAPHY

 Basavanthappa BT, (2009), Nursing Education, New Delhi, Jaypee Brothers medical
publishers.
 Vati, Joginder. Principles and Practice of Nursing Management and Administration. 1st
edition, 2013, Jaypee Brothers Medical Publishers. 647-657
 CV guide – Massachusetts Institute of Technology – Global Education & Career
Development, United States
 Cover Letter guide – Massachusetts Institute of Technology – Global Education & Career
Development, United State