What the best note includes
The fall was not witnessed. The note must therefore record what the nurse found, quote what the client said, give objective findings, and document the notification of the physician. The best entry reads: found sitting on floor beside bed; states, "I slipped on my way to the toilet"; no visible injury; physician informed at 02:20. It records facts and the client's words, not the nurse's conclusion about how the event happened.
Documenting an unwitnessed fall
Because no one saw what happened, the nurse cannot chart "slipped and fell" as a fact. The nurse can only state the observation (where and how the client was found) and the client's account, placed in quotation marks so readers know whose words they are. Objective findings follow, ideally including the assessment done, and then the notification with the time. This protects the client, the nurse, and the hospital, because the record stays accurate if questions arise later.
| Note | Problem or strength |
|---|
| "Seems unhurt and calm" | Vague impression instead of an objective finding |
| "Incident report filed at 02:30" | Mentions the incident report in the client's record |
| Found on floor; quote; no visible injury; physician informed at 02:20 | Correct: observation, quote, objective finding, notification |
| "Slipped and fell beside bed" | States an unwitnessed event as fact |
Why the incident report is not mentioned
Watch out! The incident report is an internal quality and risk management document. It is filed separately and is not part of the medical record. Writing "incident report filed" in the nursing note references a document that is meant to stay confidential and may make it accessible in legal proceedings. The nurse completes the incident report as required, but the chart contains only the clinical facts and care given.
Clinical considerations in this client
A client with liver cirrhosis may have a coagulopathy and low platelets, so a fall can cause hidden bleeding, including intracranial hemorrhage, even without visible injury. She may also have early hepatic encephalopathy that affects judgment and gait. After the fall, the nurse assesses her neurologic status and vital signs, checks for pain and injury, monitors closely for delayed signs, reviews fall precautions such as bed height, call light, toileting schedule, and nonslip footwear, and records all follow-up observations. The audit trail of the electronic record shows when each entry was written, which supports timely, honest charting.
Exam takeaway
Key point! For an unwitnessed fall: chart "found" plus the client's quoted words, objective findings, and notification. Do not write conclusions about what happened, vague impressions, or any reference to the incident report.