You charted “patient fell.”
ROOM 630 0:37 Charting
On the standWhat a lawyer asks about “Patient fell.”Did you see it? If nobody saw it, “fell” describes something you did not witness. The note has to show what you saw, what you were told, and who saw what.3 real questions · 3 court cases. What to chart instead →You charted “patient fell.”
“Patient fell.” Did you see him fall?
...No?
Didn't see it? Then you found him on the floor.
Incident report filed?
Report goes in the system. Not in the chart.
No injury?
Write what you checked. Head. Hips. Numbers.
“Fourteen-twenty. Found on floor. Fall not witnessed.”
...No further questions.
Never chart what you did not see.
Olga? Did you just fall?
...Found on floor.