Name: __________________________ Medical Record Number:_______________________
Section A
Date of Incident ________________________ Time of Incident ______________ __ AM __ PM
|
Day of Week Location |
Severity Level (check highest level of injury) Treatment (check all that apply) |
| Yes | No | |
|---|---|---|
| __ | __ | Physician notified
Name of MD __________________________________ |
| __ | __ | Family/POA notified
Name of contact _______________________________ |
| __ | __ | Medical record flagged and occurrence documented accordingly |
| __ | __ | Plan of care updated |
| __ | __ | Medical record flagged for followup documentation |
Signature: __________________________________________________ Date: ___________________
Section B
-
Was the incident:
__ Found on the floor (unwitnessed)
__ Fall to the floor (witnessed)
__ Near fall (patient lowered to floor by staff/other or stabilized)
__ Self-reported fall -
The cause of the incident was:
__ Lost balance
__ Slipped (specify): ___________________
__ Lost strength/weakness
__ Tripped
__ Lost consciousness/seizure
__ Equipment malfunction (specify): ______
__ Environmental factor (specify): ________
__ Other (specify): ___________________ -
The activity during the incident was:
__ Ambulating in bedroom
__ Ambulating to/from bathroom
__ Transferring on/off toilet
__ Sliding out of wheelchair
__ Getting up from chair/wheelchair
__ Brakes unlocked
__ Getting in/out of bed
__ Bed wheels unlocked
__ Out of low bed to floor/mat
__ Changing clothes/other ADLs
__ Getting in/out of tub or shower
__ Reaching for something
__ Other (specify): ___________________ -
Was there staff present during the activity?
__ Yes __ No
-
The footwear at the time of the incident was:
__ Shoes
__ SlippersAnd if applicable
__ No tread or tread too high/thick
__ High/narrow heel
__ Poor fit/loose
__ Plain socks only
__ Nonskid socks
__ Bare feet
__ Other (specify): __________________ -
Indicate aid in use at the time of the incident:
__ None
__ Cane
__ Wheelchair
__ Walker
__ Merry walker
__ Hip protectors
__ Other (specify): ___________________ -
Part A.
Was a restraint in use at the time of the incident?__ Yes (complete Part B)
__ NoPart B.
__ Vest/trunk restraint
__ Wrist/hand mitten
__ Seat belt/roll belt/waist restraint
__ Gerichair with table
__ Lap Buddy/lap tray
__ Other (specify): ____________________ -
Part A.
Were the side rails up?
__ Yes (complete Part B)
__ NoPart B.
__ Full length side rails (2 full or 4 half rails on both sides of bed)
__ Other side rails: ____________________ -
Part A.
Was alarm present?
__ Yes (complete Part B)
__ No - Part B (check all that apply)
__ Bed alarm sounded during event
__ Bed alarm did not sound during event
__ Chair alarm sounded during event
__ Chair alarm did not sound during event
__ Other (specify): ____________________
As a Result of This Incident
-
Did the patient's mental status change?
__ Yes __ No
-
Did the patient's level of consciousness change?
__ Yes __ No
-
Was the patient's blood glucose level checked?
__ Yes __ No
If yes, indicate: ___________________ -
Was the patient's pulse checked?
__ Yes __ No
If yes, indicate: ___________________ -
Was the patient's BP taken? __ Yes __ No
If yes, indicate value: ___________/___________
systolic diastolicIf postural BP indicated, record value:
sitting ______ systolic/ ______ diastolic
standing ____ systolic/ ______ diastolic -
Was the patient's temperature taken?
__ Yes __ No
If yes, indicate value: _______________And check
__ oral __ rectal __ axillary -
Part A. What was the incident outcome?
__ Injury (complete Part B)
__ Noninjury
- Part B. If injury, indicate site(s) injured in first column, and the type of injury for each site checked ("X" all that apply):
| INJURY SITE | TYPE OF INJURY | ||||||
|---|---|---|---|---|---|---|---|
| Left or Right | Bruise, skin tear or abrasion, laceration without suture |
Fracture | Laceration w/sutures or closed head injury |
Pain | If other, specify type of injury |
||
| Head | __ | __ | __ | __ | __ | __ | __ |
| Neck | __ | __ | __ | __ | __ | __ | __ |
| Upper spine | __ | __ | __ | __ | __ | __ | __ |
| Lower spine | __ | __ | __ | __ | __ | __ | __ |
| Shoulder | __ | __ | __ | __ | __ | __ | __ |
| Arm | __ | __ | __ | __ | __ | __ | __ |
| Wrist | __ | __ | __ | __ | __ | __ | __ |
| Hand | __ | __ | __ | __ | __ | __ | __ |
| Chest | __ | __ | __ | __ | __ | __ | __ |
| Abdomen | __ | __ | __ | __ | __ | __ | __ |
| Pelvis | __ | __ | __ | __ | __ | __ | __ |
| Hip | __ | __ | __ | __ | __ | __ | __ |
| Leg | __ | __ | __ | __ | __ | __ | __ |
| Ankle | __ | __ | __ | __ | __ | __ | __ |
| Foot | __ | __ | __ | __ | __ | __ | __ |
| Other site | __ | __ | __ | __ | __ | __ | __ |
| Other site (specify): | |||||||
- Was this person in the Falls Management Program at the time of the fall?
__ Yes If yes, send fax alert to MD.
__ No If no, consider enrollment in the Falls Management Program.
If necessary, please provide a brief narrative of this incident:
_________________________________________________________________________________________
_________________________________________________________________________________________
Confidential and privileged document prepared for quality assurance and management purposes.
