What is the primary purpose of an incident report?

• A. To log administrative details
• B. To document an accident or unusual event for quality improvement and accountability; not part of the medical record.
• C. To document patient diagnoses and treatment plans in the medical record.
• D. To bill for services rendered

Answer: (B)

The main idea is to capture safety-related events to improve care and accountability. An incident report is used to document accidents or unusual events, including what happened, when and where it occurred, who was involved, and the actions taken. The goal is to analyze patterns, pinpoint system flaws, and implement changes to prevent recurrence. It is kept separate from the patient’s medical record and is typically used by risk management and quality departments. The language should be factual and objective, focusing on what happened and what was done, not on diagnosing or treating the patient in the chart. While investigations may address accountability as part of improving safety, the report itself is not billing and does not serve as the formal clinical record of care.