Record incidents, risks and follow-up work

Some events need their own Clinical record. A Daily Care note is not enough on its own.

Use Incidents / Risk when you need to record:

• an incident
• a complaint
• a concern that needs tracking
• a risk, including falls or safeguarding
• the follow-up that belongs with that record

Use Clinical tasks when someone must do a piece of follow-up work by a due date.

If a resident is hurt or unsafe right now, help the resident first. Then write the record. The screen can wait. The resident cannot.

• Sign in and select Enter Clinical.
• Open the correct resident if the event belongs to one person.
• Have the facts: when it happened, who was present, what you saw, and who you told.
• Write only what you know. Do not guess.

Daily Care, Nurse review and Today’s Care do not create an incident for you.

1. Select Enter Clinical.
2. Open Incidents / Risk in the Clinical menu, or open the resident and then the Incidents card.
3. Start a new incident.
4. Choose the correct resident. Check the name and room.
5. Write what happened in short, clear sentences.
6. Include the date and time.
7. Say who was told, for example the nurse in charge or the Clinical Manager.
8. Save the record.
9. If follow-up is needed, add it on the same record or create a Clinical task with a due date.

Do not leave the only copy of an incident in a paper notebook, a diary, or a staff WhatsApp group.

1. Open Incidents / Risk, or open the resident’s Risk management card.
2. Start the risk record.
3. Say what the risk is, in ordinary words.
4. Add the review date your home uses.
5. Save the record.
6. Come back on the review date. Do not let the date pass with no update.

A risk record is for something that still needs watching. An incident is for something that has already happened. Use both if both are true.

1. Open Worklists, or open the resident’s Clinical tasks card.
2. Create the task.
3. Write the next action in one sentence, for example “GP to review skin” or “Family meeting to be arranged”.
4. Set a due date.
5. Save it.
6. When the work is done, update the task. Do not leave finished work looking open.

A Healthcare Assistant may record Concern identified in Care Portal. That does not create an incident, a risk or a task.

The Nurse or Clinical Manager still needs to decide:

• Is an incident needed?
• Is a risk record needed?
• Is a Clinical task needed?
• Does the care plan need an update?

Open those pages and create them. Do not assume the system has done it.

• Do not record an incident under the wrong resident.
• Do not copy gossip or guesses.
• Do not use another person’s login “because they have access”.
• Do not put safeguarding details in Family Portal.
• Do not rely on Today’s Care as the incident register. It is only a view of Daily Care.