Accurate and timely documentation of a patient fall is a fundamental responsibility in nursing practice. The nurse’s note serves as a legal document, providing an official account that can be scrutinized for years after the incident. Thorough charting ensures continuity of patient care, allowing the healthcare team to understand the circumstances, injuries, and follow-up plan. This detailed record also contributes to quality improvement efforts by providing data to help prevent future occurrences.
Initial Steps Following a Patient Fall
The immediate response following a patient fall must prioritize patient safety and data collection. The first action is to assess the patient, ideally without moving them, to determine the extent of any injury and stabilize their condition. This assessment includes checking vital signs, level of consciousness, and asking the patient what happened, as this subjective data is valuable for the record. The nurse should perform a rapid head-to-toe check for visible trauma, such as abrasions, lacerations, or swelling, and note any complaints of pain.
The assessment should focus on neurological status, as head injuries may not be immediately apparent. This involves checking for changes in consciousness, pupillary response, and cognitive status. Serial neurological assessments may be necessary for the next 24 to 72 hours, depending on facility protocol. Concurrently, the nurse should assess the environment to identify potential contributing factors, such as whether the bed alarm was on, side rails were positioned correctly, or if hazards like wet floors were present.
Once the patient is stabilized, the nurse must initiate notifications and interventions. This involves calling for assistance and notifying the supervising nurse and the healthcare provider. Any orders received from the provider, such as for X-rays or laboratory tests, must be recorded and promptly executed. The nurse’s note should reflect the exact time and content of these communications to demonstrate compliance with the standard of care.
Constructing the Detailed Nursing Note
The nursing note must be a factual, objective, and chronological narrative of the event and the subsequent care provided. The note begins with the precise time and location the patient was found, and their condition at that moment. If the nurse did not witness the fall, they must avoid stating the patient “fell” and instead document exactly what was observed, such as, “Patient was found sitting on the floor beside the bed.”
Objective documentation relies on using facts and avoiding subjective conclusions or blame. If the patient or a witness provides information, it should be documented using quotation marks and clearly attributed, for example, “Patient stated, ‘I tried to get up to use the bathroom and my legs gave out.'” Subjective phrases like “patient appeared confused” should be replaced with observable data, such as “Patient was disoriented to place and time.”
The sequence of the note should detail the findings of the post-fall physical assessment. Specific findings, such as the presence or absence of new pain, skin integrity changes, or range of motion limitations, must be recorded precisely. Documentation must also include the immediate nursing interventions performed, such as assisting the patient back to bed, applying ice, or initiating a new neurological check frequency.
Finally, the note must account for all communication and follow-up activities. This includes the time the physician was notified, the specific orders received, and the implementation of those orders. The nurse must also document any patient and family education provided regarding the fall and the revised plan of care. The entry must be authenticated with the nurse’s signature, credentials, and the time the note was written.
The Role of the Incident Report
Beyond the patient’s medical record, a separate document known as an Incident Report (or Safety/Variance Report) is completed after a patient fall. This report serves a distinct purpose from the nursing note, acting as a risk management tool for internal quality improvement and system analysis. The focus of the Incident Report is to identify patterns, root causes, and areas where changes in policy, equipment, or environment can prevent similar events.
The Incident Report is not part of the patient’s medical record and is generally protected from discovery in legal proceedings. Nurses must adhere to the rule of never referencing the Incident Report in the patient’s chart. Writing a phrase such as “Incident Report filed” compromises the confidential nature of the report, potentially making it accessible to external parties.
While the content of the Incident Report often mirrors the factual details of the nursing note, it is completed on a separate form and submitted to administration or risk management. The nursing note is the official, legal record of the patient’s condition, the circumstances of the event, and the care provided. The Incident Report, in contrast, is an internal mechanism for organizational learning and safety analysis.