You’re walking down the hall when you hear a sudden thud from Room 204. Your heart pounds as you rush in to find Mr. Henderson on the floor next to his bed. After you ensure he’s okay and call for help, a daunting question hits you: “Do I need to fill out a cna incident report?” This is a moment every CNA faces, and the uncertainty can be paralyzing. This guide will give you the clear-cut answer and the confidence you need to handle this critical responsibility like a pro.
So, Can a CNA Complete an Incident Report? The Direct Answer
Yes, you can—and in most situations, you absolutely should. In nearly every healthcare facility, Certified Nursing Assistants are not only permitted but expected to complete an incident report. Your role as the eyes and ears of the nursing team makes you essential to this process.
However, it’s not a free-for-all. Your ability to fill out an incident report falls under two important sets of rules: your state’s cna scope of practice and your specific facility’s policies. Let’s break that down.
Scope of Practice vs. Your Facility’s Policy
Think of it like this: your cna scope of practice gives you the what, and your facility’s policy gives you the how.
Your scope of practice, defined by your state’s board of nursing, gives you the authority to perform tasks like observing patients and reporting changes. Filling out an incident report is a formal extension of your duty to report. It’s a core cna responsibility.
Your facility’s policy, on the other hand, dictates the specific procedure. It tells you exactly which form to use, who needs to be notified, and the timeline for filling out an incident report. You must follow your facility’s protocol to the letter to protect yourself, your patient, and your employer.
Clinical Pearl: Always know where to find your facility’s incident reporting policy. It’s usually in the employee handbook or on the intranet. Familiarize yourself with it before an incident happens.
What Constitutes an “Incident” That Needs Reporting?
An incident is any unusual or unexpected event that could or did result in harm to a patient, visitor, or staff member. As a CNA, you are often the first to witness these events.
Here are the most common situations that require an incident report from a CNA’s perspective:
- Falls: Any time a patient is found on the floor.
- Skin Injuries: This includes pressure injuries, cuts, scrapes, or skin tears you discover or witness.
- Medication Errors: If you witness a medication being given incorrectly, at the wrong time, or to the wrong patient.
- Patient Altercations: Any instance of a patient becoming physically or verbally aggressive towards staff or another patient.
- Property Damage: When a patient or visitor damages facility equipment.
- Adversive Reactions: Witnessing a patient have a negative reaction to a treatment or procedure.
Imagine you’re helping Mrs. Garcia, who is normally cheerful and cooperative, with her lunch. She suddenly becomes confused, slumps in her chair, and is unable to speak. You immediately call for the nurse. This is a significant change in condition that absolutely requires an incident report, documenting what you observed before, during, and after the event.
Pro Tip: When in doubt, report it. It is always better to file an incident report for something minor than to fail to report something that becomes serious. Your primary role is patient safety.
The Golden Rules: How to Properly Document an Incident
Proper documentation is your superpower. An objective, factual report protects you legally and professionally. The opposite—a sloppy or emotional report—can create huge problems. Here is your step-by-step guide.
- Notify Your Nurse Immediately: Before you do anything else, verbally inform the charge nurse or supervising nurse of the situation. This is the most critical step.
- Stick to the Facts: The incident report is for what you saw, heard, or did. Period. It is not a place for theories, opinions, or blame.
- Be Timely: Fill out the report as soon as possible after the event, while the details are fresh in your mind. Most facilities require this within 24 hours.
- Use Objective Language: This is the hardest part for many new CNAs. Let’s look at a comparison.
| Objective Statement (What to Write) | Subjective Statement (What NOT to Write) |
|---|---|
| “Patient found lying on the floor, right side of body, wearing a hospital gown.” | “Mr. Smith was probably trying to get out of bed by himself again.” |
| “Observed a 1cm linear scrape with minimal bleeding on patient’s left forearm.” | “Mrs. Davis had a nasty cut on her arm from scratching it.” |
Winner/FBest For: The objective column is the only acceptable choice. It provides clear, unbiased information for anyone who reviews the report.
Common Mistake: Writing “I felt so bad for him” or “It was a scary situation.” Your feelings have no place in the document. Keep it professional and clinical.
What NOT to Include on an Incident Report
Understanding what to leave out is just as important as knowing what to include. Your credibility as a healthcare professional depends on it.
- NO Blame: Do not write things like, “The CNA on the previous shift didn’t put the call light in reach.” The report is not to assign fault.
- NO Speculation: Avoid writing, “The patient must have been confused.” You don’t know that for a fact. Report the behavior, not the presumed cause. Write, “Patient was observed pulling at their bed rails and looking around the room.”
- NO Opinions: Words like “tiny,” “large,” “minor,” or “severe” are subjective. Use measurements. “2 cm abrasion” is factual. “Small abrasion” is an opinion.
- NO Discussion of Fault: Never admit fault or apologize in the report. Statements like “It was my fault I left the side rail down” can have significant legal ramifications for you and your facility.
A Quick Checklist for Perfect Reporting
Before you submit that report, run through this mental checklist:
- [ ] Did I clear this with the nurse first?
- [ ] Is my report based only on facts?
- [ ] Have I included dates, times, and locations?
- [ ] Did I quote the patient or others directly if necessary?
- [ ] Is my language objective and professional?
- [ ] Did I sign and date the form?
What Happens After You Report?
Once you’ve submitted your factual report, your direct responsibility is typically complete. The baton is passed to the nursing leadership team.
The charge nurse will review your report and conduct their own assessment. They will add their clinical findings to the patient’s chart and a copy of the incident report may be reviewed by the unit manager, the risk management department, and the quality assurance team.
The report itself becomes an internal document used for investigation, process improvement, and legal protection. It is not part of the patient’s permanent medical record. This separation is key—documentation for cnas in an incident report serves a different purpose than a chart entry.
Remember, you did your job by observing and reporting accurately. Trust the system to take it from there.
Conclusion: Your Role as a Patient Advocate
Learning how to write a proper cna incident report transforms the task from a scary liability into a powerful act of advocacy. By reporting clearly, factually, and immediately, you protect your patient, your license, and your facility. Your primary role is to observe, report, and communicate. Mastering this skill doesn’t just make you a compliant employee; it makes you an exceptional and confident CNA.
Have you ever been unsure about filing a report or had an experience that taught you a valuable lesson? Share your story or ask a question in the comments below—let’s learn from each other!
Want more career-boosting CNA tips like this delivered to your inbox? Sign up for our weekly newsletter to get exclusive resources and expert advice.
Found this guide helpful? Share it with your CNA classmates and colleagues on social media to help them build their confidence, too