Which document records an unusual event or near-miss during care?

• A. Chart note
• B. Incident report
• C. Discharge summary
• D. Informed consent

Answer: (B)

Capturing safety events to improve care is the main idea here. An incident report is the document used when something unusual happens or a near-miss occurs during care. It focuses on what happened, when, where, who was involved, contributing factors, and what actions were taken or suggested to prevent recurrence. This type of report is often kept separate from the patient’s formal chart to support safety analysis and quality improvement, while protecting confidentiality.

A chart note records the patient’s current condition, observations, assessments, and the care provided as part of the medical record. It documents events, but not in the specific incident-reporting format used for safety near-misses. A discharge summary summarizes the hospital stay, treatments, and follow-up plans at discharge. Informed consent shows that the patient agreed to a treatment after being informed of risks and alternatives.

So, the document that records an unusual event or near-miss during care is the incident report.