CELBAN - Canadian English Language Benchmark Assessment for Nurses Writing Incident Reports Questions and Answers 1 — Questions and Answers
Question 1: When writing an incident report, which of the following statements is the most appropriate and professional?
- The patient seemed confused and was probably trying to get out of bed.
- Patient found on floor at 07:30. Stated, "I was trying to reach my water glass and I slipped." (Correct answer)
- I believe the patient fell because the side rails were left down by the night shift nurse.
- The patient was careless and fell while unsupervised.
Correct answer: Patient found on floor at 07:30. Stated, "I was trying to reach my water glass and I slipped."
This statement is the most appropriate because it is objective and factual. It states the time, what was observed, and includes a direct quote from the patient without adding any personal opinions, assumptions, or blame.
Question 2: A nurse is preparing an incident report after a patient received the wrong dose of medication. Which of the following details is LEAST necessary to include in the report?
- The nurse's opinion on why the error occurred. (Correct answer)
- The patient's vital signs after the error was discovered.
- The name of the medication and the incorrect dosage given.
- The notification of the patient's physician.
Correct answer: The nurse's opinion on why the error occurred.
Incident reports should be factual and objective. Including personal opinions, speculation, or blame is inappropriate and unprofessional. The other options are all critical facts of the incident that must be documented.
Question 3: You are a nurse who witnessed a visitor slip and fall on a wet floor in the hospital hallway. The visitor states they are not injured, but you insist on completing an incident report. What is the primary purpose of writing this report?
- To ensure the visitor receives a bill for the assessment.
- To discipline the cleaning staff responsible for the wet floor.
- To document the event for risk management and quality improvement. (Correct answer)
- To create a record to protect the visitor in a future lawsuit.
Correct answer: To document the event for risk management and quality improvement.
The main purpose of an incident report is to serve as a tool for the healthcare organization to track and analyze events for risk management, identify patterns, and implement changes to improve safety and quality of care. It is not primarily for billing, discipline, or legal action for the injured party.
Question 4: Which of the following BEST describes the type of language that should be used when writing the narrative portion of an incident report?
- Subjective, descriptive, and detailed.
- Technical, using many medical abbreviations.
- Objective, factual, and chronological. (Correct answer)
- Concise, using personal judgment and conclusions.
Correct answer: Objective, factual, and chronological.
Incident reports require clear, objective, and factual language. The events should be described in the order they occurred (chronologically) without including personal feelings, judgments, or assumptions.
Question 5: A nurse finds a patient on the floor beside their bed. After assessing the patient and ensuring their immediate safety, the nurse calls the physician. What is the next most appropriate action regarding documentation?
- Make a detailed entry in the patient's chart stating that an incident report was completed.
- Complete the facility's incident report form and place a copy in the patient's chart.
- Document the factual details of the fall and the physician notification in the patient's chart. (Correct answer)
- Wait for the supervisor's instructions before writing anything.
Correct answer: Document the factual details of the fall and the physician notification in the patient's chart.
The nurse should document the objective facts of the incident (what was seen, the patient's condition, actions taken) in the patient's medical record. The incident report is a separate, internal administrative tool and reference to it should not be made in the patient's chart.
Question 6: When documenting an incident, which piece of information is considered 'subjective' data?
- The patient's blood pressure reading of 140/90 mmHg.
- A 3 cm laceration observed on the patient's forehead.
- The patient stating, "I feel dizzy." (Correct answer)
- The patient's bed was found in the lowest position with side rails up x2.
Correct answer: The patient stating, "I feel dizzy."
Subjective data is information reported by the patient that cannot be directly measured or observed by the healthcare provider. The patient's feeling of dizziness is their personal experience. The other options are objective data, which are measurable and observable facts.
CELBAN - Canadian English Language Benchmark Assessment for Nurses Writing Incident Reports Questions and Answers 1
When writing an incident report, which of the following statements is the most appropriate and professional?