Documentation to keep your license

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Specializes in ED.

If a pt falls, what is the best way to document?  I've always been told to not document falls in a chart.  Why?

Also, if a nurse leaves without giving report, how do you document that, when you take over the assignment?

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Specializes in Hospice.

Not documenting a fall can have serious repercussions for you, your patient and your facility. What shouldn't be documents in the chart is the incident report that would be generated. I would also avoid mention in the chart of the behavior of another staff member. Beginning your note with something like "Assumed care of pt at …” is sufficient.

Both the behavior of staff and the investigation of incidents are administrative issues, not medical. Making them part of a discoverable legal record could open an unnecessary can of worms for everyone involved.

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Specializes in Critical Care, ER and Administration.

If you witness the fall, then yes, you should document the fall. You should also document injuries and actions taken. If you did not witness the fall, then document, "Patient found on floor." I would not document that there was no report given. Just document that you assumed care. However, I would report it to my supervisor. If a nurse leaves a patient without giving a report, it is abandonment in the eyes of the law and the BON.

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Oh my goodness.  Under no circumstances is it okay NOT to document a fall. 

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