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Defines what must be recorded (date, exact time, location, event type, people involved, witnesses), how to write a factual narrative in sequence using first-person observations, and how to document immediate actions, assessment, care decisions, apparent injury or none observed, and follow-up ownership. Provides notification logging requirements, reviewer/signature routing to risk management or QA separate from the clinical record, and cautions against blame, cause-guessing, and sharing identifying information with consumer AI tools.",{"@graph":63,"@context":112},[64,80,95],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/incident-adverse-event-report-cheat-sheet-bastiongpt-clinical-advisory-board/572646/",4,{"url":78,"name":59,"@type":81,"author":82,"headline":59,"publisher":85,"fileFormat":88,"inLanguage":57,"description":61,"dateModified":89,"datePublished":89,"encodingFormat":88,"isAccessibleForFree":90,"interactionStatistic":91},"DigitalDocument",{"name":83,"@type":84},"miaandmiso","Person",{"url":68,"name":86,"@type":87},"DocShare","Organization","application/pdf","2026-10-13",true,{"@type":92,"interactionType":93,"userInteractionCount":4},"InteractionCounter",{"@type":94},"ViewAction",{"@type":96,"mainEntity":97},"FAQPage",[98,104,108],{"name":99,"@type":100,"acceptedAnswer":101},"What information should be recorded at the start of an incident report?","Question",{"text":102,"@type":103},"Record the date, exact clock time, precise location, and event type. Near misses also count.","Answer",{"name":105,"@type":100,"acceptedAnswer":106},"How should the factual narrative be written?",{"text":107,"@type":103},"Write in first person and in sequence, only what was seen and heard, using the words people used. Avoid conclusions, blame, and cause-guessing.",{"name":109,"@type":100,"acceptedAnswer":110},"Where should the report be routed, and what should be kept out of the clinical record?",{"text":111,"@type":103},"File it with risk management or practice QA, apart from the clinical chart. 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It is kept apart from the clinical record; the chart gets the clinical impact only. |  |\n| --- | --- |\n| Event basics the clock starts here\u003Cbr>Do: record the date, exact clock time, precise location, and event type; near misses count.\u003Cbr>Pitfall: \"during the afternoon shift\" instead of a time; regulator deadlines run from when you knew. |  |\n| Persons involved and witnesses who was there\u003Cbr>Do: name who was affected (client, visitor, staff) and every witness, with role and contact.\u003Cbr>Pitfall: the unlisted witness; unreachable by the time anyone investigates. |  |\n| Factual narrative the discipline of the form\u003Cbr>Do: write first person, in sequence, only what you saw and heard; keep the words people used. Pitfall: conclusions, blame, or cause-guessing; they turn a QA record into an admission. |  |\n| Immediate actions and care the response on paper\u003Cbr>Do: record the assessment offered, first aid, the EMS decision, and what the person chose. Pitfall: an event with no documented response reads as neglect even when care was given. |  |\n| Injury and outcome leave the file ajar\u003Cbr>Do: state apparent injury or \"none observed,\" plus a follow-up window and an owner. Pitfall: \"no injury\" closing the file at the scene; some injuries surface days later. |  |\n| Notifications made duties, dated and timed\u003Cbr>Do: log each person and agency notified with date, time, and by whom; know your deadline.\u003Cbr>Pitfall: the missed clock; CMS next business day, NDIS and aged care 24 hours, Saskatchewan 3 days. |  |\n| Reporter identity and review the observer signs\u003Cbr>Do: have the person who observed the event write and sign; a supervisor reviews and dates. Pitfall: secondhand authorship; a report by someone who was not there loses its value. |  |\n| Routing and the chart the split that protects it\u003Cbr>Do: file with risk management or QA, apart from the chart; chart the clinical impact only. Pitfall: \"incident report filed\" in a progress note invites discovery of the whole file. |  |\n\nBefore you file  \n Written by the person who saw it  \n Exact times: event, response, notifications  \n Facts in sequence; no blame, no cause-guessing  Care offered, given, or declined recorded  \n Outcome carries a follow-up window and owner  Every required notification, dated and timed  Chart holds the impact, not this report  \n\n| Drafting with AI\u003Cbr>Capture the facts while they are fresh: what you saw, clock times, who was there, what you did, who you told. |\n| --- |\n| \u003Cbr>\"Draft an objective incident report from these facts, first person, no conclusions: client fall, 2:47 PM, waiting room, ice pack\u003Cbr>accepted, EMS declined, owner notified 3:35 PM.\" |\n| Never paste client-identifying information into consumer AI tools. BastionGPT is HIPAA-compliant with a signed BAA onevery plan. |\n\n\n| 300 to 600 words | 15 to 30 min by hand | Same day | Risk mgmt · QA · carriers |\n| --- | --- | --- | --- |\n| typical length | clinical team estimate | faster clocks may apply | who reads it |\n|  |  |  |  |\n\nFull guide and sample report:  \n[bastiongpt.com/template/incident-report](bastiongpt.com/template/incident-report)  \nBastionGPT drafts objective incident reports from your bullets. Free 7-day trial.  \nPractice/program: Report \\#: Date of event: Time:  \n\n| Exact location: | Person affected (initials): | Role (client / visitor / staff): |\n| --- | --- | --- |\n\nEvent type  \nFall · medication error · elopement · aggression or assault · restraint or seclusion · self-harm or suicide attempt · death · privacy event · near miss · other  \nWitnesses  \nName, role, and contact for each person who saw any part of the event  \nFactual narrative  \nFirst person, in sequence, on","cbCais8eYC783WRq","https://ap.wps.com/l/cbCais8eYC783WRq","pdf",115111,"English","# Event basics the clock starts here\n# Persons involved and witnesses who was there\n# Factual narrative the discipline of the form\n# Immediate actions and care the response on paper\n# Injury and outcome leave the file ajar\n# Notifications made duties, dated and timed\n# Reporter identity and review the observer signs\n# Routing and the chart the split that protects it\n# Practice/program: Report","[{\"question\":\"What information should be recorded at the start of an incident report?\",\"answer\":\"Record the date, exact clock time, precise location, and event type. Near misses also count.\"},{\"question\":\"How should the factual narrative be written?\",\"answer\":\"Write in first person and in sequence, only what was seen and heard, using the words people used. Avoid conclusions, blame, and cause-guessing.\"},{\"question\":\"Where should the report be routed, and what should be kept out of the clinical record?\",\"answer\":\"File it with risk management or practice QA, apart from the clinical chart. The clinical record should chart only the clinical impact, not references to the report.\"}]","Incident & Adverse Event Report Cheat Sheet - BastionGPT Clinical Advisory Board | PDF"]