Unusual Occurance

[BlearnRN]

A pt strolls up to the floor from admitting and falls before she gets to the room. The nurse taking the pt had to do a unusual occurance, but should he do a note in the chart also - he did not witness the fall.

[Christie RN2006]

I personally might chart something along the lines of (Pt stated "I tripped and fell in hallway". Pt noted to be walking without difficulty and no redness or bruising noted. Pt denies pain. MD notified. Will continue to monitor)

Why was this newly admitted patient alone in the hallway? None of our patients walk to their rooms, they are either brought by wheelchair or bed and never left alone.

[BlearnRN]

I have no idea why this pt was not in a chair coming up to our floor. I did say something to the director about pt coming up to the floor without a w/c.

[UM Review RN, ASN, RN]

I have no idea why this pt was not in a chair coming up to our floor. I did say something to the director about pt coming up to the floor without a w/c.

Our direct admits often walk to the unit themselves.

I would definitely chart it, as well as make out an incident report (we've had bizarre things like a patient's relative falling and breaking a bone in the parking lot, so we actually have a policy on this) that describes that Patient had a bed assignment but had not been fully admitted at the time of the occurrance.

And of course, when charting, you'd write "Patient states" there was an unwitnessed fall....

[Elvish, BSN, DNP, RN, NP]

As far as I know, you should indeed chart in the nurse's notes, whether it's a "Pt states...." or a "Pt found on floor in hallway; states,...." Document your post-fall assessment, when you notified the MD, if any new orders given, etc. And continue to chart on the patient's condition if warranted (which it usually is).

[flightnurse2b, LPN]

we always have to write out an incident report.. i always put "found on the floor/no witness. pt stated (whatever)....", whoever found the patient writes the note, and then the primary nurse charts location, pre-fall condition (if known), post-fall condition, MD notified/time/new orders or interventions, vitals, etc....