Post-Fall Assessment Note

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

Date/Time of Fall: [Date and time of fall, or "unknown" with last-known-well time]

Location: [Unit, room, specific area]

Witness Status: [witnessed / unwitnessed / found on floor / patient-reported]

Author/Role: [Name, credentials/role]

Event Summary

[Brief narrative of fall event] (Write 3–6 sentences covering: how fall was discovered; head strike status [confirmed/denied/unknown]; loss of consciousness [confirmed/denied/unknown]; presence or absence of red-flag symptoms; immediate actions taken; initial disposition. Include patient quotes for mechanism or symptoms when available. Use "unknown" with reason if details unavailable.)

Assessment

Vital Signs: [Post-fall vitals with time] (Include orthostatics if clinically indicated.)

Neurologic Status: [Mental status, pupils, speech, motor strength/symmetry, focal deficits, headache compared to baseline] (If baseline unknown, state sources checked.)

Injury Examination: [Findings by region including skin integrity, tenderness, deformity, ROM] (For suspected extremity injury, include distal neurovascular status.)

Pain: [Location, intensity, quality]

High-Risk Modifiers: [Anticoagulant/antiplatelet use with agent and last dose if known], [bleeding disorder], [osteoporosis], [cognitive impairment affecting history reliability] (Document as applicable.)

Head Injury Evaluation: [Relevant clinical findings informing imaging/monitoring decision] (Complete if head strike confirmed or unknown, anticoagulated, or concerning symptoms present. Document specific inputs: mechanism, symptoms, risk factors, exam findings.)

Notifications & Orders

Provider Notification: [Name/role], [date/time], [response and orders or "no new orders"]

Family/Representative: [Name], [date/time], [response] (Per facility or LTC requirements.)

Charge Nurse/Supervisor: [Name], [date/time] (If required by policy.)

Orders: [Imaging, labs, neuro checks with frequency/duration/escalation criteria, pain management, wound care, PT/OT consult as applicable]

Pending Results: [Item, expected timeframe, responsible party, reassessment plan]

Interventions & Plan

Interventions Performed: [Assistance/transfer, wound care, pain management with medication/dose/route/time, patient response]

Possible Contributing Factors: [Patient factors, medication factors, environmental factors, communication/workflow factors as identified] (Use "possible contributing factor" language; do not assign blame.)

Updated Fall-Prevention Plan: [Patient-specific interventions mapped to identified risk factors: observation level, toileting/rounding, mobility aids, alarms, environment modifications, education provided] (Note when plan will be reassessed and pending evaluations.)

Monitoring & Disposition: [Scheduled reassessments], [escalation triggers], [current disposition: remained on unit / transferred to ED / other]

(Use explicit "unknown" or "unable to assess" with reason rather than leaving blanks. Note pending information with responsible party. Document observed facts and clinical findings only. Internal safety event reports are completed separately per facility policy.)