Falls Documentation

Remember were in the home health forum...most of our patient falls don't have a witness....and often pts will decline to tell us they've fallen for fear we will put them in a nursing home. By the time they tell us, it may be days/weekes later as it slips out in conversation/ complaint of aches 'n pains.

For home health, following apply:

a. Record statement in patients own words.

b. Gentlly probe about how,where, at what time and in what circumstances the fall occurred, wearing footware?

c. Assess the client for signs injury, abrasions, range of motion, obvious injury

d. Notify PCP re above.

These days I'd even fax my note to the office as backup documentation

e. Obvious injury and can't get hold of PCP, recommend pt go to the ER.

When they refuse, call back Drs answering service to have on record patient refusal.

f. Safety assessment of fall area

g. Contact next of kin if patient forgetful/cognitive impaired or apparent injury and refusing treatment so family can follow-up with patient

and get PCP appointment.

h. Review when patient last had PT eval ..if not within past 2-3 weeks, request eval from PCP.

i. Revisit within 2-3days.

Witnessed:

a. Write what you observed about fall

b. Any statement made to patient prior to falling on that day re safety that patient ignored during visit

e.g "Oberved patient in past at gas stove while wearing Oxygen prongs, had O2 tubing stretched across top of kitchen chair and table...told her it was a safety hazzrd, should not be at stove with oxygen on and better to have tubing on the floor. Husband today walked into kitchen, did not see tubing, walked into it causing patient to be pulled backward, falling onto floor."

c. Patient assessment, note any injuries incurred, action on how patient is lifted from floor, any treatment given or recomended.

d. Apparent injury with limb/hip at odd angle,and patient refusing care, call 911 over objections of patient --second assessment pair of eyes can sometimes convince need to go to the hospital.

e. Call doctor and relatives -informed of the incident.

f. Notify nursing supervisor above.

g. Reschedule visit 24-48hrs if not admitted hospital.

h. include f + h from above.