How to write a good incident note

A good incident note has: date and time, objective facts (what you saw and heard, not opinions), the client's condition, actions you took, and who you notified. Your agency's own incident form governs — this checklist helps you fill it.

1. 1Date, time, and location of the incident.
2. 2What you directly observed — quote the client's exact words when relevant ('I feel dizzy'), describe what you saw ('sitting on the floor next to the bed').
3. 3Facts, not opinions: write 'red 3cm mark on left forearm', not 'someone grabbed her'.
4. 4Client's condition before and after.
5. 5What you did, in order (checked responsiveness, called 911, stayed with client…).
6. 6Who you notified and when (supervisor, nurse, family, 911, EndHarm).
7. 7Complete it the same day while details are fresh.

Never include another client's information, and never enter the client's full name into apps or personal notes — use your agency's official form for identifying details.