Incidents Overview
If you haven't already done so, please read Visit and Incident Records Compared before continuing!
Summary
A central distinction in the software is the one between incidents and visits. A visit occurs in the clinic when you provide services to the patient. The incident is what occurred somewhere else (we hope!) which gave the patient reason to come to the clinic. Since the visit and the incident are logically different things, the software carries separate but related records for each. When you register a patient for a new injury, illness, or exposure visit, the software will automatically create an Incident record. All follow-up visits for this injury, illness, or exposure will be linked to the same incident which was created for the initial visit. So, a single incident can have multiple visits attached to it. It is also possible for an incident to be entered independently of any visit, although it would be unusual to do this for an Occupational Health or Urgent Care visit.
What information goes in the incident record?
The program includes powerful functions to enable you to document numerous details of the incident for clinical and safety purposes, as well as track the work restrictions, follow-up visits, lost or modified duty time, costs, etc. How much of that gets entered varies greatly, depending on the type of the incident and clinic procedures. As we walk through all the features, don't get overwhelmed-the software has been designed to support a very wide range of uses. The fact is, in an Occupational Health setting, you will probably not use very many of the incident features. For Urgent Care, you will use even fewer.
The visit record contains the activity that occurred while the patient was in the clinic such as the physician seen, activities performed and charting notes made. The Incident record carries information which relates to the injury, illness, or exposure, and which is common to all visits associated with the incident. It can be divided into several categories:
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The basics: Nature of incident, body part and zone, case identification, case physician, diagnosis, work status.
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About healthcare: referrals, work restrictions, exposure follow-up scheduling, lost time, case costs.
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Billing: responsible payer, controverted case, claim number.
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About the event: safety log, OSHA log, sharps log, job and department at time of injury.
For your convenience, certain information about the incident is entered on the [Enter Visit] screen. Don't let that confuse you! It is still stored in the incident record. The diagnostic codes, problem statement, work restrictions, etc. entered on the initial visit will all apply to all follow-up visits as well, without your reentering them.
Types of incidents
While injuries, illnesses and exposures have a great deal in common when it comes to managing their documentation, each one also has some specific needs. Therefore, when you first add an incident record, you specify whether the incident is an injury, illness or exposure. The choice you select determines other fields and tabs that are displayed on the screen, and also determines how the incident is classified for the OSHA Log and other reporting purposes.
To accurately capture and report incident data, the program provides a number of Incident Safety Codes. Once the items on each table A user-definable list of items that helps ensure consistency in data capture so that reports are meaningful. are defined, the table is accessed from the incident record during documentation.
The program also includes a wide array of Incident and Follow-Up reports to assist you in the many tasks associated with employee incidents. In addition, the (optional) Case Management module provides the capacity to document case notes (distinct from nursing or physician notes) and set ticklers to remind you of case actions you plan to take. It also includes a number of case management reports which users have found quite helpful over the years. (In Net Health Employee Health and Occupational Medicine , the terms "Incident" and "Case" are synonymous.)
To assist you in learning about employee incidents, please use the browse sequences to follow the topics. First, read the Employee Incident Record sequence of topics, then the Employee Incident Entry sequence. A few topics are repeated in both sequences for clarity purposes. Finally, read the separate sequence for Employee Exposures.
What absolutely must be entered?
Most of what is really needed will be entered on the [Enter Visit] window, and will be obvious given the type of visit and clinic procedures. This includes the diagnosis, problem statement, work status, work restrictions, and referrals. We strongly recommend that you enter three fields directly on the incident for use in reporting. These are especially important for thorough reporting to employers in and Occupational Health setting. The Nature of Incident puts injuries into broad categories which can help employer's take steps to reduce injuries. Body Part and Body Zone give more detail to those reports.
See Also