Accurate, timely, and objective documentation of a patient fall is a fundamental requirement for the professional nurse. Comprehensive fall documentation acts as a vital communication tool for the multidisciplinary team, ensuring the continuity of safe patient care and informing future prevention strategies. The official nurse’s note serves as the permanent legal record, necessary for the facility’s quality improvement efforts and for protecting both the patient and the healthcare provider.
Immediate Clinical Response and Initial Assessment
The nurse’s first priority upon discovering a fall is not documentation, but the patient’s immediate safety and stabilization. The initial response must prioritize life-saving measures, beginning with a rapid assessment of the patient’s airway, breathing, and circulation (ABC) status. If a life-threatening injury is suspected or the patient is unresponsive, emergency medical services and the facility’s rapid response team should be activated immediately.
After ensuring the patient is stable, a focused physical assessment is necessary to identify any potential injuries before moving the patient. The nurse must check for signs of trauma, such as open wounds, bleeding, or obvious fractures, and assess the patient’s level of consciousness. If there is any indication of a spinal or major limb injury, the patient should not be moved until a medical practitioner assesses them.
The assessment includes obtaining a full set of vital signs, noting any changes from the patient’s established baseline, and checking for common post-fall indicators like a drop in blood pressure or an increase in pulse. The nurse should also attempt to determine the circumstances of the fall by asking the patient or any witnesses what happened and what the patient was doing immediately beforehand. All immediate interventions, such as applying pressure to a bleeding site or repositioning for comfort, must be completed before the nurse begins the written record.
Principles of Objective Narrative Documentation
The nurse’s note in the official medical record is a formal, legal document that requires the use of objective, non-judgmental language. The entry must be charted as soon as possible after the event and the initial assessment, ensuring the timestamp reflects the precise moment the entry was recorded. This documentation must focus exclusively on observable facts and the care provided, avoiding speculation or assigning any blame for the incident.
A comprehensive fall note must detail the patient’s status immediately before the fall, if that information is known, such as the last time the patient was seen or their stated intent. The note must then describe the exact location where the patient was found and their position, such as “found on the floor parallel to the bed, lying on their left side.” This description helps future reviewers understand the mechanism of the fall.
The physical findings from the initial head-to-toe assessment must be recorded, including the absence or presence of specific injuries, such as “no skin tears, contusions, or obvious deformities noted.” The nurse must also document the patient’s subjective statements, such as “patient denies pain or dizziness,” using direct quotes whenever possible. Finally, the note must list every intervention performed, including assisting the patient back to bed, initiating neurological checks, and notifying the physician and family, with the specific times for each action.
Differentiating the Clinical Note from the Facility Incident Report
Nurses are typically required to complete two separate forms of documentation following a fall: the clinical note in the patient’s medical record and the facility’s internal incident report. The clinical note is a permanent part of the patient’s legal medical record, and its primary purpose is to communicate the clinical event, assessment findings, and care plan to other healthcare providers. This documentation is focused on the patient’s health status and treatment.
The incident report, however, is a confidential, internal document used by risk management and quality improvement teams to analyze trends and prevent future occurrences. It is not part of the patient’s permanent medical record and should never be referenced within the nurse’s clinical note. For example, the clinical note should not state, “Incident report completed.”
This distinction is important because the incident report may contain subjective details, staff analysis, or quality-related information that is inappropriate for the legal medical record. By keeping the two documents separate, the facility maintains the integrity of the clinical record while ensuring that internal safety and quality data are collected for systems analysis.
Post-Fall Monitoring and Continued Care Documentation
Following the initial assessment and intervention, the nurse’s documentation shifts to reflect the continuous monitoring required after a fall. Increased vigilance is necessary, often for up to 72 hours, because a fall can lead to delayed symptoms or indicate a decline in condition. This period requires frequent, time-stamped reassessment notes.
These follow-up entries must detail the patient’s ongoing neurological status, particularly if a head injury was suspected or the fall was unwitnessed, with assessments of pupil response, level of consciousness, and cognitive function. The nurse must document the patient’s response to any new interventions, such as the status of any identified injuries, changes in pain level, and repeated vital signs.
Documentation must also include the implementation of any new fall prevention measures or changes to the care plan. All communication must be clearly documented with the time and method of communication.
- New fall prevention measures, such as the use of an alarm, bed mats, or increased supervision.
- Communication with the physician, including specific orders received.
- Notification of the patient’s family or legally authorized representative.