Which of the following is true of incident reports?

• A. Incident reports should always contain a combination of facts, opinions, and eyewitness accounts.
• B. Incident reports should only be completed at the resident's request because of privacy issues.
• C. Incident reports should only be completed by doctors after they have assessed the resident's condition.
• D. Incident reports should contain the facts of the incident and the actions taken to give care.

Answer: (D)

Incident reports document what happened and the care that followed. The statement that incident reports should contain the facts of the incident and the actions taken to give care is the right one because these notes must be objective and specific so relationships of events, observations, and responses are clear. This kind of documentation supports accurate communication among staff, continuity of care for the resident, and opportunities to review and improve safety practices. Reports should include details like what occurred, who was involved or witnessing, when and where it happened, what was observed, and the immediate actions taken (assessments, treatments, notifications). Opinions or interpretations aren’t appropriate in these records; they should reflect verifiable facts. While doctors may review and add input as needed, these reports are typically completed by the care team promptly after the incident, and they remain confidential within the resident’s chart. Privacy matters, but that does not mean reports are generated only at the resident’s request.