Category: Incident Reports

It seems like a no-brainer to keep diligent track of all major incidents that occur with your patients – and it is.

What is often not understood is how important this documentation plays a part in making sure all benefits are getting utilized from insurance carriers.

If your facility has either JCAHO or CARF then you do not have an option when it comes to incident reports. These must be diligently kept in order for you to keep your accreditation. If you are not accredited, this video can give a quick glance on where to start:



An incident report should be filed every time there is something out of the ordinary that happens. This is especially true for mental health and addiction treatment centers – adults and adolescents included.

Although an incident that needs to be reported can set back progress and hinder treatment, it also has a good chance of triggering a patients behavioral health benefits to kick in. Knowing how each incident potentially plays into one of your patients getting access to key benefits in their insurance policy can play a huge part in a successful outcome from treatment.

Reporting incidents in drug treatment programs or adolescent behavioral health facilities can provide a number of benefits:

  • Proper reporting can show gaps in processes and opportunities for program inprovments
  • They can help identify key needs in staff training, where further continuing education is needed
  • Helps clinical staff review and adapt care/treatment plans
  • Can set a benchmark for a clinical team to measure performance against
  • JCAHO or CARF accreditation requires immaculate record keeping – best to start now
  • This type of documentation can be an important part of a legal defense – hopefully never needed of course

substance abuse billing incident reports

What are some of the types of incidents you should record?

  • Death or impending death of a patient
  • Suicide/homicide attempt
  • Sexual assault or rape
  • Physical abuse
  • Physical harm or threat to self or community
  • Need for law enforcement, fire station, or medical emergency professionals (ambulance)
  • A centennial event that would be news worthy
  • Any possession of a violent or deadly weapon during any level of care
  • Any violation of an individual’s rights
  • Admission to hospital because of serious injury or illness
  • Outbreak in the community of a serious contagious disease

incident reporting form in drug rehab

What processes should be set up when an incident occurs?

  1. Connect verbally and in writing (incident report) with clinical team no later than 24 hours after the occurrence.
  2. Key information that cannot be left out: patient name, age, level of care, date, time, location of incident, staff on duty, detailed description of the occurrence, if medical care was needed, and the current status of the patient.
  3. Establish a follow up plan of action and contact any necessary outside sources.
  4. *Establish a quality assurance process to review incidents quarterly.


It is important that both clinical and support staff are aware of the importance of these reports, and that they take time to review them. It is on the management of the facility to make sure both staffs are reporting on timely and consistent basis. This is especially important when your facility relies on insurance billing for substance abuse or behavioral health as a means of revenue. There should be a dedicated point person or email group that your third party insurance billers have access to as well.