Falls Documentation

[athomemom56]

I need some pointers on documenting falls. Just want to see what others do. What do you document when 1.The fall happened prior to your coming to work or 2. The fall happened while you were there and you witnessed it.....Include what action you would or did take also. I just like to see the way others do things. Never too old to learn more.

Thanks,

Barbra

[nightmare, RN]

I need some pointers on documenting falls. Just want to see what others do. What do you document when 1.The fall happened prior to your coming to work or 2. The fall happened while you were there and you witnessed it.....Include what action you would or did take also. I just like to see the way others do things. Never too old to learn more.

Thanks,

Barbra

The nurse in charge of the shift should document falls on her shift(different country,maybe different rules)It is difficult to document a fall when you are not the nurse who examines the patient for any possible injury.

We have a standard form we fill in.The first part is a statement about how,where at what time and in what circumstances the fall occurred.

The next is action taken after the fall.Examination,note of any injuries incurred,action on how patient is lifted from floor(hoist etc),action on any treatment given and if the doctor and relatives are informed at the time of the incident.

The next section is for witness statements and then the notifying nurse signs the form. Hope this helps.

[NRSKarenRN, BSN, RN]

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.

[athomemom56]

Very Good information. And yes, it is in reference to home health. THanks much.

Barbra