Report Writing

Three areas for consideration Case Notes Communication of information to facilitate effective clinical management Incident Forms Communication of information to facilitate effective risk management Clinical Practice Register for Physical Restraint Requirement by MHC to record incidents of restraint

HSE POLICY All incidents (physical and non-physical) shall be identified, reported, communicated and investigated in accordance with the Safety, Health and Welfare at Work Act 2005 and the prevailing HSE Incident Management Policy and Procedure. Employees should be familiar with and where appropriate trained in incident reporting, management and review. The process of incident reporting and management includes the following steps: 1. Identification 2. Immediate Management 3. Reporting (Completion of incident form) 4. Incident Investigation 5. Closing the Incident Management Loop

Value of Incident reporting Identification of patterns. Improvement of patient care. Safety of environment. Improved staff safety, health and welfare. Prevention

Why do we complete an incident report? Provide record of incident. Document the facts. Alert risk management department. Provide information for statistics. Basis for investigations.

Recording clinical practice guidance to nurses (An Bord Altranais 2002) Section 7- Guidelines for good practice in recording clinical practice. Reports should be Accurate, clear and current Legible, signed and dated. As soon as possible after incident Date and time- 24 hour clock

Mental Health Commission-Code of Practice. Section 5: Recording the use of Physical Restraint. - Record in residents file. As soon as possible record should be made in clinical practice form for physical restraint. Completed forms should be placed in the residents file and a copy available for review on request. (MHC 2006)

Debriefing Debriefing must be attempted with service user after each episode of restraint by a staff member/keyworker who was not involved in the incident with the aim of reconnecting the service user and the treatment team. Outcome of this debriefing is documented in his/her Individual Care Plan. (MHC, 2014 p.27 & 29)

References and Further Reading Mental Health Commission (2014) Seclusion And Restraint Strategy. Dublin: Stationary Office. Mental Health Commission (2006) Code of Practice on the Use of Physical Restraint in Approved Centers. Dublin: Stationary Office. An Bord Altranais (2002) Recording Clinical Practice Guidance. Dublin: An Bord Altranais.