Reporting and recording incidents
It is important for the client and those working with them that any unacceptable behaviour be recorded and those records kept on their files. This includes any formal observation and monitoring records. These can then be analysed and any specific patterns identified for future reference or action. If the unacceptable behaviour includes violence and/or a major incident, then any workers involved need to file an Incident Report. A copy of this Incident Report should be kept on the client’s file, as well as being submitted to the appropriate managers for follow-up.
Recording an incident report
These records need to be detailed and specific for each incident that has occurred, including the following details:
- Type of incident – abuse, threat, assault
- Who was abused/threatened or assaulted, and their occupation
- Client/person who committed the act and relevant details
- Description of the location, where it took place
- Activity underway at the time, including detailed description of any high-risk activities
- Time of occurrence and day of the week
- Nature of injuries sustained
- How the incident arose and progressed
- Contributing causes
- Potential or actual costs
- Corrective action recommended
- Follow-up recommendations.
Note: When recording an incident always stick to the facts; avoid statements that could be interpreted as ill feeling, personality conflicts or dislike of the client or his or her condition.
Recording violent incidents/outbursts for management purposes
These records are those that are kept at management level for the purpose of crisis management and policy review and development.
Record all incidents, threats or physical attacks relating to clients and staff of the agency, including:
- Separate record of each incident
- Date, time, place
- Name of client or perpetrator
- Details of what happened
- Names of any witnesses.
General rules regarding correspondence
For correspondence to the client or their family following any incidents:
- All correspondence must be retained
- Any statements made by victim to deny or correct remarks, statements or claims by the client should be recorded
- Date all statements and enter the dates mailed or delivered to the client
- If there has been a reply from the client or their representative, attach to record and date
- If there is no reply or response from the client, this should also be recorded.
For correspondence from the client following any incidents:
- All correspondence must be retained
- Any statements made by the perpetrator to deny or correct remarks, statements or claims made by the victim should be recorded
- Date all statements.
For records of correspondence between service provider, client or liaison group:
- Meetings between a service provider and client should be recorded with the date, items discussed and names of those present
- Written correspondence should be dated and copies filed
- Verbal discussion notes, including telephone discussions (date, time, people involved) should be dated and filed.
Some statistics that agencies keep for management purposes include:
- Type and severity of incident (i.e. major, minor, and near miss events)
- Incidences occurring in a particular unit/residence as relevant
- Client characteristics (e.g. medical condition, history of aggression and the type of service being provided)
- Possible cause or contributing factors (e.g. delays in service provision)
- Specific location in agency
- Other factors (e.g. time, date).
If there are individuals who have been victims of any violence or aggression, they should also keep a record of the incident and any remedial action taken.
Unacceptable behaviour in clients can be predictable and, in some cases, preventable when the evidence from previous incidents is available to be examined objectively. Each incident or event needs to be documented separately and kept on file in a suitable location. This information can be very useful:
- For managers (statistics can be used for planning and for policy development).
- For workers (these records can keep everyone informed and more prepared for any future incident).