How to write a good incident note
2 min readDocumentation — objective observation and reporting
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.
- 1Date, time, and location of the incident.
- 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').
- 3Facts, not opinions: write 'red 3cm mark on left forearm', not 'someone grabbed her'.
- 4Client's condition before and after.
- 5What you did, in order (checked responsiveness, called 911, stayed with client…).
- 6Who you notified and when (supervisor, nurse, family, 911, EndHarm).
- 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.
Call 911 immediately if
Client is unconscious, not breathing normally, bleeding heavily, or you suspect a head, neck, or spine injury.
What to remember
- —Date, time, and location of the incident..
- —What 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')..
- —Facts, not opinions: write 'red 3cm mark on left forearm', not 'someone grabbed her'..