“Patient fell.” What gets asked about a fall note, and what to chart instead
Exhibit 1 after a fall
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.
What they ask about it
An expert witness reviewing a fall (NSO risk article, questions by Patricia Iyer)
Immediately after the fall: How soon was the individual found after he had sustained a fall (it’s not always possible to establish an exact time)? What was done at the time of the fall?
A trial court reading a nurse's fall note, quoted on appeal
What else might have happened that Starkey did not record in her note?
Was Nurse Starkey close to Mr. McIlvain (or even present in his room) when she spotted him out of bed, or was she farther away, perhaps in the hallway, when she saw him? How quickly did Mr. McIlvain fall after Starkey first spotted him: was it instantaneous, or did Mr. McIlvain only fall after an appreciable moment or more?
A plaintiff firm, explaining fall notes to families
Families may hear softer labels in the first phone call or chart note, such as “slid,” “assisted,” “lowered to the floor,” or “found on the floor.” Those phrases are easier to swallow, but they can also blur the reality of the event and delay the next steps that are supposed to follow. ... did the resident end up on the floor or another lower surface in an unplanned way? If so, it should be treated as a fall unless the documentation clearly shows otherwise.
The plaintiff's nursing expert read a post-fall note as describing the moment of the fall. The doctor who wrote it showed, from how she laid the note out, which lines were what she was told and which were what she saw when she walked in, and the court believed her.
Dr. Vong explained that it was her “habit” to first document information she obtained after being paged by a nurse. According to Dr. Vong, she then skipped a line in her notes to distinguish “all the information I’ve gathered after I’ve gone to see the patient.”
Appellate Division, Third Department, New York · 2023
After an unwitnessed fall, the nursing notes still described the old level of supervision, and a nurse testified that what is not documented cannot be known. The court found questions of fact for trial.
after decedent had an "unwitnessed" fall on December 8, 2015 demonstrating that decedent was not being provided one-to-one supervision the nursing notes continued to indicate that decedent was on "15 minute safety checks" ... as testified to by at least one nurse during her deposition, it was not possible to know whether something was completed if it was not documented.
The only nurse who saw the fall could not testify, so her note was the whole account, and the plaintiff's expert argued from what it left out. The hospital still won on causation.
At the time, Nurse Starkey charted the events as follows: pt found walking into bathroom per self. Was asked if he needed any help. pt proceeded towards toilet, lost balance and fell. ... Alvin stated her belief that had the nurse assisted McIlvain, she would have written that in the chart.
Write instead
0215 Pt found on floor beside bed, lying on L side. Fall not witnessed. Call light within reach, bed in low position, bed alarm sounding on arrival. Pt states he was trying to get to the bathroom.
For example, if you did not actually see the patient fall, you would not document that the patient fell. If you walked into the room and the patient was sitting on the floor and said they fell, that's exactly what should be documented with the words “the patient stated” in quotations. This would represent the facts of the findings.
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.