Unwitnessed fall documentation example 2026

1. Click ‘Get Form’ to open the unwitnessed fall documentation example in the editor.
2. 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.
3. 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.
4. Document when the patient was last rounded on and assess which factors were evaluated during rounds, marking all that apply.
5. Specify the physical location of the fall and whether it was witnessed or assisted. If staff assisted, note any transfer equipment used.
6. Complete SECTION B: POST FALL CHECKLIST by confirming MD notification and updating necessary care plans and progress notes as required.
7. 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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