Fall/Incident Report (Home Health)

Note Type: Fall/Incident Report (Home Health)

Author: [Author name, credentials, discipline]

Documentation Date/Time: [Date and time of documentation]

Patient Location at Assessment: [home / community / facility - specify]

How Incident Became Known: [witnessed by clinician / reported by patient / reported by caregiver / phone call / other]

Mode of Assessment: [in-person visit / phone / video]

Event Summary

[1–3 sentence plain-language summary of what happened, known injury status, and disposition] (Include whether the event was witnessed, and whether head strike or loss of consciousness occurred if known. Avoid speculation.)

Incident Details

• Incident Type: [fall (unassisted) / fall (assisted/lowered to floor) / intercepted fall/near-fall / other incident - specify]
• Witnessed: [yes / no / unknown] (If unwitnessed, specify who discovered the patient and last known activity/position.)
• Location/Setting: [bathroom / bedroom / kitchen / living room / hallway / stairs / outdoors / other - specify]
• Activity at Time: [toileting / transferring / ambulating / reaching / turning / bed mobility / other - specify]
• Footwear/Assistive Device Status: [barefoot / socks / shoes - type]; [assistive device present and used / present but not used / not available / device malfunction]
• Environmental Contributors Observed: [rugs / clutter / wet surface / poor lighting / pets / cords / uneven surface / equipment issues / none apparent] (List all that apply.)
• Mechanism as Described: [Patient or caregiver description of how fall occurred] (Label the source. Use direct quotes only if materially affecting interpretation.)

Timeline

• Time of Incident: [exact time / approximately / unknown]
• Time Discovered: [exact time / approximately / same as above / unknown]
• Time Clinician Notified: [exact time / approximately / unknown]
• Time Clinician Assessed: [exact time / approximately]
• Time EMS Contacted: [exact time / approximately / not applicable]
• Time EMS Arrived: [exact time / approximately / not applicable]
• Time MD/APP Notified: [exact time / approximately / pending]
• Time Orders Received: [exact time / approximately / none / pending]

Assessment

Immediate Safety Screen: [Apparent distress level]; [Airway/breathing concerns: present / none]; [Active bleeding: present / controlled / none]; [Safe to remain in place: yes / no] (If unsafe, document immediate actions taken.)

Symptoms and Patient-Reported Concerns: (Label source as patient or caregiver.)

• Pain: [location], [severity 0–10], [quality], [onset/duration]
• Dizziness/lightheadedness: [present / absent]
• Chest pain: [present / absent]
• Shortness of breath: [present / absent]
• Weakness: [present / absent] (Specify distribution if present.)
• Numbness/tingling: [present / absent]
• Headache: [present / absent]; [severity if present]
• Nausea/vomiting: [present / absent]
• Visual changes: [present / absent]
• Confusion/speech difficulty: [present / absent]
• Pre-fall symptoms: [description or none reported] (Label source.)

Injury Assessment:

• Visible injuries: [bruising / laceration / abrasion / hematoma / skin tear / none] with [location and size in cm]
• Suspected fracture indicators: [deformity / shortening or rotation / inability to bear weight / severe focal tenderness / crepitus / none]
• Musculoskeletal function: [range of motion, strength, weight-bearing ability, transfer ability] (Assess only if safe.)
• Head/Neck considerations: [scalp/facial injuries]; [neck pain: present / absent]; [anticoagulant/antiplatelet use: yes / no / unknown] (Include if head impact suspected or confirmed.)

Vital Signs: (Document values or reason not obtained.)

• Temperature: [value / not obtained - reason]
• Pulse: [value / not obtained - reason]
• Respirations: [value / not obtained - reason]
• Blood Pressure: [value / not obtained - reason]
• SpO2: [value and device / not obtained - reason]
• Pain score: [0–10]
• Orthostatic vitals: [supine BP/HR], [standing BP/HR after 1–3 min], [symptoms] (Include if syncope, near-syncope, dizziness, or hypotension suspected.)
• Blood glucose: [value / not obtained - reason] (Include if diabetes, altered mentation, or hypoglycemia concern.)

Neurologic Assessment

(Include when head strike suspected/confirmed, loss of consciousness, new confusion or focal deficits, severe headache, vomiting, or patient on anticoagulation. If not indicated, state: "Focused neurologic exam not indicated based on mechanism and presentation.")

• Level of consciousness and orientation: [alert / drowsy / obtunded]; [oriented to person, place, time, situation / disoriented - specify]
• Speech: [clear / slurred / aphasic - describe]
• Pupils: [size, equality, reactivity / not assessed]
• Motor function: [strength by limb], [symmetry], [drift: present / absent]
• Sensory: [intact / deficits - describe distribution]
• Gait/balance: [stable / unsteady / not assessed - reason] (Assess only if safe.)
• Neuro monitoring plan: [frequency of checks], [who will perform: clinician / trained caregiver], [red flags that prompt 911] (If adequate monitoring cannot be ensured, document escalation actions taken.)

Disposition and Escalation

Outcome: [remained in home with monitoring plan / urgent clinic appointment arranged / EMS activated with ED transfer / family transported to ED / patient refused recommended evaluation or transport]

• If transferred: Destination: [ED / urgent care / facility - specify]; Mode: [EMS / private vehicle]; Accompanied by: [name/relationship]; Medication list/documents sent: [yes / no]
• If patient refused recommended evaluation/transport: Capacity observations: [coherent understanding, able to paraphrase risks/benefits / impaired - describe]; Recommended action and rationale explained: [summary]; Risks discussed and patient response: [brief description or quote]; Alternative plan agreed upon: [plan]; Notifications made: [MD/APP / family/POA / supervisor] with [date/time]; Safety-net instructions provided: [specifics]

Interventions Performed

• First aid/wound care: [cleansing / dressing / bleeding control / ice / elevation / none required]; Response: [improved / unchanged / worsened]
• Immobilization/mobility restrictions: [splinting / brace / non-weight bearing / limited activity / none] (Specify per standing orders vs. new provider orders.)
• Safe transfer/positioning: [technique used]; Equipment: [device and settings]
• Environmental safety actions: [removed throw rug / improved lighting / reorganized pathways / secured cords / other / none at this visit]
• Medications administered: [name, dose, route, time] per [standing order / new provider order / patient self-admin]; Response: [effect and any adverse reactions]
• Post-intervention status: Pain [improved / stable / worsened]; Vitals [stable / unstable]; Activity tolerance [description]

Notifications and Communications

(Document each notification separately. Include read-back confirmation for verbal orders per policy.)

• Contact: [Name and role: MD/APP / clinical manager / PT / OT / caregiver/family/POA] — Date/Time: [date and time] — Method: [phone / EHR message / in-person]
  Information Communicated: [situation, relevant background, key assessment findings, recommendation or request]
  Response/Orders Received: [orders or instructions received] (Include read-back confirmation if verbal order.)

Follow-Up Plan

1. Monitoring window and parameters: [duration, typically 24–72 hours depending on risk]; Monitor [pain / swelling / bruising / neuro status / mobility / vitals as indicated]
2. Who will monitor and frequency: [clinician visit schedule], [phone check schedule], [caregiver monitoring frequency]
3. Escalation triggers: Symptoms requiring 911: [specific list]; Symptoms prompting call to agency/MD: [specific list]
4. Visit frequency/discipline involvement: [RN frequency], [PT/OT referrals and frequency], [other disciplines]
5. Care plan updates: [fall prevention interventions], [equipment needs], [transfer training], [medication review request], [provider follow-up appointments], [pending labs or imaging]

Patient/Caregiver Education

• Education provided: [injury-specific red flags], [safe mobility and transfer techniques], [environmental modifications], [when to contact agency vs. 911]
• Teach-back confirmation: [patient/caregiver accurately repeated key points / needs reinforcement - specify topics]

Addendum

(Use for information learned after initial documentation, such as imaging-confirmed fracture. Include date/time of addendum, source of information, and concise update. Do not alter the original narrative.)

Documentation conventions: For required elements that are unavailable, use "Unknown," "Not witnessed," "Not assessed - [reason]," or "Not applicable" rather than leaving blank.