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Click ‘Get Form’ to open the unwitnessed fall documentation example in the editor.
Begin with SECTION A: FALL EVENT DETAILS. Fill in the date and time of the fall, ensuring you select the correct department or nursing unit where it occurred.
Indicate the patient's fall risk level prior to the incident by selecting from options such as Low, Moderate, or High. Confirm if a falls risk wristband was worn at the time.
Document when the patient was last rounded on and assess which factors were evaluated during rounds, marking all that apply.
Specify the physical location of the fall and whether it was witnessed or assisted. If staff assisted, note any transfer equipment used.
Complete SECTION B: POST FALL CHECKLIST by confirming MD notification and updating necessary care plans and progress notes as required.
Finally, move to SECTION C: MINI ROOT CAUSE ANALYSIS. Fill in details about who conducted this analysis and document findings regarding the reasons for the fall.
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Heres what you should gather: Incident report. If you reported the slip and fall to a property owner or manager, obtain a copy of the official report they created. Photographs and videos. Medical records. Witness statements. Personal notes. Clothing and shoes. Proof of lost income.
How do you describe an unwitnessed fall?
An unwitnessed fall is a silent incident, occurring without the watchful eyes of care professionals or cognitively able residents. Its a challenging predicament, leaving families grappling with uncertainty and concern over the wellbeing of their loved ones.
How will you assess a patient with a witnessed fall?
After the Fall Check the patients breathing, pulse, and blood pressure. Check for injury, such as cuts, scrapes, bruises, and broken bones. If you were not there when the patient fell, ask the patient or someone who saw the fall what happened.
How to document a witnessed fall?
Use your phone or a camera to document the scene from multiple angles. Key details to focus on include: The hazard that caused the fall Take close-ups and wide shots of wet floors, loose carpeting, uneven surfaces, debris, or any other condition that contributed to the accident.
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unwitnessed fall nursing note example
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