Skip to content
View in the app

A better way to browse. Learn more.
allnurses

A full-screen app on your home screen with push notifications, badges and more.

To install this app on iOS and iPadOS
  1. Tap the Share icon in Safari
  2. Scroll the menu and tap Add to Home Screen.
  3. Tap Add in the top-right corner.
To install this app on Android
  1. Tap the 3-dot menu (⋮) in the top-right corner of the browser.
  2. Tap Add to Home screen or Install app.
  3. Confirm by tapping Install.
Discussion

Documentation to keep your license

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?

  • Quote

    • Featured Replies

    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.

  • Quote

    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.

  • Quote

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

  • Quote

    • Join the conversation

    You can post now and register later. If you have an account, sign in now to post with your account.

    Guest
    Add a Comment
    Go to topic listing

    Currently Reading 0

    • No registered users viewing this page.

    Account

    Navigation

    Search

    Search

    Configure browser push notifications
    Chrome (Android)
    1. Tap the lock icon next to the address bar.
    2. Tap Permissions → Notifications.
    3. Adjust your preference.
    Chrome (Desktop)
    1. Click the padlock icon in the address bar.
    2. Select Site settings.
    3. Find Notifications and adjust your preference.