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Incident Report Documentation Guide

Know exactly what to document, when to report through CHRIS, and how to build corrective action plans that satisfy DBHDS requirements.

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6 sections covering the full incident lifecycle — from initial documentation through quality improvement trending.

What Must Be Reported to DBHDS

Virginia DD waiver providers must report serious incidents to DBHDS through the CHRIS system. Understanding what qualifies as reportable prevents both under-reporting (a licensing violation) and over-reporting (which creates unnecessary administrative burden).

Deaths — all deaths of individuals receiving services must be reported within 24 hours regardless of cause or location
Serious injuries — fractures, head injuries, burns requiring medical treatment, or any injury requiring emergency room visit or hospitalization
Medication errors requiring medical intervention — wrong medication, wrong dose, or missed medication that requires medical attention or produces adverse effects
Allegations of abuse, neglect, or exploitation — any allegation, whether from the individual, staff, family, or external party, must be reported immediately
Unauthorized use of restraints — any physical, mechanical, or chemical restraint not documented in an approved behavior support plan
Missing person — individual absent from the service location without staff knowledge for a duration that poses safety risk
Law enforcement involvement — any interaction with police, arrest, or legal action involving the individual
Hospitalizations — psychiatric or medical hospitalizations, including voluntary admissions

Reporting Timelines & Deadlines

Missing a reporting deadline is itself a compliance violation. Timelines vary by incident severity.

Deaths: Report to DBHDS within 24 hours. Mortality Review completed within 10 business days.
Level III incidents (serious injuries, abuse/neglect allegations): Report to DBHDS within 24 hours through CHRIS
Level II incidents (less serious but still reportable): Report within 72 hours through CHRIS
Level I incidents (internal tracking): Document internally within 24 hours, no CHRIS report required
Adult Protective Services (APS) referral: Required immediately for any abuse/neglect allegation involving an adult
Internal incident report: Complete within 24 hours of the event regardless of level
Root cause analysis for Level II and III: Complete within 30 days of the incident
Corrective action plan follow-up: Document implementation and outcomes per the timeline established in the plan

What to Document in Every Incident Report

A complete incident report answers who, what, when, where, and how. Missing any of these elements creates audit findings and weakens your documentation if the incident is reviewed later.

Date, time, and exact location of the incident — be specific (e.g., "kitchen of 123 Main St" not "the house")
Names of the individual(s) involved and any witnesses, including staff and non-staff
Factual description of what happened — chronological, objective, no opinions or conclusions
Immediate actions taken by staff — first aid, calling 911, contacting supervisor, separating individuals
Notifications made — who was called, at what time, and what was communicated (supervisor, guardian, case manager)
Individual's condition after the incident — physical state, emotional state, any statements made by the individual
Staff member completing the report — name, title, signature, date and time of report completion
Photographs of injuries, damage, or scene conditions taken at the time of the incident

Root Cause Analysis (RCA)

Identify contributing factors: staffing levels, training gaps, environmental hazards, communication breakdowns, individual-specific triggers
Review incident history: has a similar incident occurred before with this individual or at this location?
Examine whether existing protocols were followed — if yes, the protocol may need revision; if no, determine why

Corrective Action Plans

Each corrective action should address a specific contributing factor identified in the root cause analysis
Assign each action to a specific person by name with a defined completion date
Include measurable indicators of success — how will you know the corrective action is working?

Get the Full Guide

Download all 6 sections including root cause analysis templates, corrective action plan worksheets, and a printable incident documentation checklist.

Quick Reference: Reporting Deadlines

Incident Type	CHRIS Report	Internal Report
Death	24 hours	24 hours
Serious injury / abuse allegation	24 hours	24 hours
Level II reportable incident	72 hours	24 hours
Level I (internal only)	Not required	24 hours
Root cause analysis (Level II/III)	Within 30 days	Within 30 days
Mortality Review	Within 10 business days	Within 10 business days

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