“No injury noted.” What an expert asks about a post-fall note
Exhibit 2 after a fall
No injury noted.
What did you check? It is a conclusion. It does not show the assessment behind it, and a fracture or a bleed may not show in the first minutes.
What they ask about it
An expert witness reviewing a fall (NSO risk article, questions by Patricia Iyer)
Was the patient appropriately monitored after the fall to detect injuries? What did the assessment (including vital signs) reveal? Did the nurse communicate the findings to the patient’s provider? Were X-rays ordered and performed? Was there an injury? If so, how soon was it treated?
The plaintiff's nursing expert, reading the post-fall notes at trial
The attending nurse’s notes from that night indicate Lee was found lying on the floor on his left side. Lofton explained the notes indicate only one “neuro-check” was done after the fall, and no head-to-toe exam was completed.
The expert measured the post-fall assessment by what the notes showed was done. The physical therapist found the hip fracture the next day, and the verdict against the facility was affirmed.
She testified the post-fall assessment of Lee failed to meet the standard of care. ... According to Lofton, had the nurses done a correct post-fall assessment, Lee’s hip deformity and hip fracture would have been discovered earlier than the next day, which is when the physical therapist discovered the injuries.
The fall note ended with “No other apparent injuries noted.” and a hip fracture was found afterward. The hospital won on causation, but the line sits in the record next to the fracture.
Was asked if anything hurt, said only rt inner upper leg. Abrasion noted on rt fa. No other apparent injuries noted. {¶ 4} Following his fall, it was determined that McIlvain suffered a right hip fracture which was surgically repaired.
A negative first assessment did not end the case. The appeals court reversed summary judgment: whether the nursing notes in the following days were accurate is a question for trial.
Here, the estate’s claims revolve around whether Fleenor’s care plan required two people to roll his shower chair into the shower, whether the appropriate shower chair was used, whether appropriate care was rendered to Fleenor after the shower chair tipped backwards, whether staff took appropriate measures to have Fleenor evaluated, whether nursing notes reflected an accurate assessment of Fleenor’s condition in the days after his fall, and whether appropriate information was communicated to Fleenor’s physician and family.
Write instead
Head-to-toe: no lacerations, bruising, or swelling noted. Legs equal length, no external rotation. Moves all extremities, full ROM without pain. Pt denies hitting head. Pain 0/10.
Each step should be documented in the patient’s health record, especially all assessment results and provider notifications. The expert witness can then see that the nurse followed a logical progression, with thorough evaluation and follow-up.
If a fall is unwitnessed by staff or it is unknown if the patient hit their head during a fall, serial neurological assessments should also be implemented to ensure no mental deterioration.
Do not edit the finding afterward. A Texas nurse was disciplined after changing a documented foot finding to within normal limits (as summarized by a nurse-attorney firm; the board order itself not checked here).
Additionally, the RN inaccurately documented that the patient had a completely rotated right foot to ninety (90) degrees but could walk normally, then edited the documentation to reflect that the musculoskeletal system was within normal limits.
Every change shows. The record keeps the time of each entry and each deletion.
Correct your charting errors in accordance with your organization’s policies and procedures, ensuring that it is clearly marked as a late entry. Remember: electronic healthcare records automatically date and time each entry and identify electronic deletions, so any attempt to alter the patient healthcare information record is discoverable.
Not to protect yourself. A note added after an incident to cover the gap reads as guilt.
Don’t chart defensively after an incident has occurred. This is a red flag to lawyers later on. Defensive charting is not necessarily going to stand up in court as actual evidence of negligence, but it does telegraph the message that you believe you were at fault, and that’s the red flag the lawyers will be looking for.
Got a subpoena or a deposition notice? Call your liability insurer and your risk manager before anything else.
The first action nursing professionals should take is to inform their professional liability insurance provider and employer’s risk manager or legal counsel of the deposition notice.
The hospital's lawyer is not your lawyer. They represent your employer.
Keep in mind that this attorney is not your attorney, but is your employer’s attorney; therefore, you may wish to retain a board certified healthcare attorney or a litigation attorney to be “on your side” for the deposition.
You can describe your routine. What you always do is evidence too, but it is weaker than the note.
You can speak about your custom and practice in general at deposition, but there is no substitute for a well-written note and initialed treatment boxes.
Not legal advice. Your facility policy, your state and your
own attorney are what bind you. Every question and every quote here links to
where it was published; read the source, not us. Written by a med-surg RN,
ten years, day shift. Why there is no name on it.