# Situation: A 64-year-old woman with liver cirrhosis is admitted to the medical ward because of vomiting and increasing abdominal girth. The ward writes its nursing notes in focus charting and uses charting by exception on its assessment flow sheets. Its electronic health record keeps an audit trail that shows when each entry was written. At 02:10 the next night, the nurse finds the client sitting on the floor beside her bed. No one saw what happened. The client says, "I slipped on my way to the toilet." After assessing her and informing the physician, the nurse writes a note. Which note is BEST?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630360  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 64-year-old woman with liver cirrhosis is admitted to the medical ward because of vomiting and increasing abdominal girth. The ward writes its nursing notes in focus charting and uses charting by exception on its assessment flow sheets. Its electronic health record keeps an audit trail that shows when each entry was written.

At 02:10 the next night, the nurse finds the client sitting on the floor beside her bed. No one saw what happened. The client says, "I slipped on my way to the toilet." After assessing her and informing the physician, the nurse writes a note. Which note is BEST?

## 보기

1. Found sitting on floor beside bed. States, "I slipped on my way to the toilet." Seems unhurt and calm. Physician informed at 02:20.
2. Found sitting on floor beside bed. States, "I slipped on my way to the toilet." No visible injury. Incident report filed at 02:30.
3. Found sitting on floor beside bed. States, "I slipped on my way to the toilet." No visible injury. Physician informed at 02:20. **✔ 정답**
4. Slipped and fell beside bed on her way to the toilet. No visible injury. Physician informed at 02:20.

**정답: 3**

## 해설

When a fall is not witnessed, the nurse records what was found and quotes what the client said, not a conclusion about what happened. The note should give objective findings and the notification, and it must not refer to the incident report, which is filed separately.

## 심화 해설

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.

## 임상 시나리오

Charting an Unwitnessed FallFacts, quotes, and notification only
Record what was found ("sitting on floor beside bed"), the client's exact words in quotation marks, an objective finding such as no visible injury, and the physician notified at 02:20.

Do not write "slipped and fell" as fact when no one saw it, and avoid vague impressions such as "seems unhurt."

The incident report is filed separately and is never mentioned in the client's record.

CautionCirrhosis may cause coagulopathy. Monitor neurologic status and vital signs closely after any fall, even without visible injury.

## 핵심 개념

- **Unwitnessed fall** — A fall that no one observed, documented as what was found and what the client reported.
- **Incident report** — An internal risk management document filed separately from the medical record.
- **Objective data** — Information observed or measured by the nurse, as opposed to the client's statements.
- **Audit trail** — An electronic log showing who wrote or changed each record entry and when.
- **Coagulopathy** — Impaired blood clotting, common in liver cirrhosis, that raises bleeding risk after a fall.

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