An adverse incident typically requires completion of both clinical documentation entered as part of the medical record and an Adverse Incident Report.
While both types of documents may describe the same event, they serve different purposes and should not simply repeat the same information. Use the table below to understand what belongs in each helps support continuity of care and appropriate internal review.
Medical Record | Adverse Incident Report |
| Purpose | |
| To document factual, accurate, and objective information about the client’s clinical presentation, assessment, treatment, interventions, and ongoing plan for care. | To provide an internal summary that includes relevant context and process-related details pertaining to a significant clinical event to support awareness, review, coordination, and follow-up. |
| Primary Use | |
| Supports ongoing clinical care, communication, and continuity. May also be shared with the client or a third party (e.g., payors or other treating providers) as permitted or required by law, regulation, or policy. | Supports internal awareness, review, coordination, and follow-up by the Clinical Risk Management Team and other appropriate internal stakeholders. |
| Part of the Medical Record? | |
✅ Yes | ❌ No |
| Include in your documentation | |
✅ Clinical presentation, symptoms, observations, and relevant client statements/disclosures ✅ Clinical assessment, formulation, and rationale ✅ Interventions provided or recommended ✅ Safety planning, referrals, and care coordination ✅ Client response to interventions, recommendations, and referrals ✅ Follow-up plan and ongoing treatment recommendations | ✅ Description of the event or concern ✅ How and when the event became known ✅ Relevant contextual information ✅ Actions taken and outcomes ✅ Individuals, agencies, or collateral contacts involved, when applicable ✅ Remaining concerns or follow-up needs |
| Avoid in your documentation | |
❌ References to the adverse incident report or internal incident reporting ❌ Internal consultation or discussions ❌ Internal policies or procedures ❌ Speculation, assumptions, or personal opinions ❌ Verbatim transcripts of sessions or messages unless clinically appropriate ❌ Excessive detail unrelated to the client’s care | ❌ Copying or pasting the progress notes, psychotherapy notes, or messaging transcript verbatim ❌ Irrelevant historical or clinical information not related to the event ❌ Speculation, assumptions, or personal opinions ❌ Excessive clinical detail that does not help explain the event, actions taken, outcome, or follow-up needs ❌ Information outside your direct knowledge unless it is clearly identified as reported by another source ❌ Unnecessary sensitive information that does not contribute to review, coordination, or follow-up |