— 照護管理 · MEDIUM · MCQ —
護理師填寫事故報告（Incident Report）時，應包含哪些資訊？
A nurse is documenting a client incident report. What information is appropriate to include?
- AThe nurse's hypothesis on why the client fell護理師對於病人跌倒原因的主觀假設
- BA copy of the incident report in the patient's medical record事故報告副本放入病人病歷中
- CObjective facts of the incident and actions taken✓ 正解事故的客觀事實與已採取的措施
- DAn admission that the nurse was distracted承認護理師當時分心
— Explanation · 中文詳解 —
事故報告的目的是品質改善而非懲罰。應僅記錄客觀事實（時間、地點、發生經過、護理處置）與臨床發現。禁止包含主觀臆測、情緒化評論、自我責備的語句。且事故報告屬於院內機密文件，嚴禁放入病歷中，以避免法律糾紛。
Incident reports should contain only objective facts regarding the event, including timing, location, and nursing interventions, to support quality improvement. Subjective hypotheses, admissions of guilt, or personal opinions must be excluded, and the report itself should never be placed in the patient's medical record.
✦ 台美臨床差異
台美對於 incident report 的定義類似。美國多電子化管理；台灣醫院在填寫事故報告時常擔心被懲處，導致隱匿，需建立不責難文化。