What to chart after a patient falls (and what to leave out)

Your patient is on the floor. Or was, a few minutes ago. Now you have a note to write. It has to tell the next nurse, the provider, and whoever opens the chart two years from now what you saw, what you checked and what you did. No guesses. No blame. No opinions.

The short version

• Chart only what you saw. Nobody saw it happen? Then the patient was found on the floor. Not fell. And don't reconstruct a fall you didn't see.
• Write the assessment in numbers and specific findings. Vitals, neuro check, head-to-toe, ROM, pain score. Plus what you checked and didn't find.
• Record every notification with a time. Who you called, when, what you told them, what they ordered.
• Keep charting the follow-up checks your policy requires. Actual values every time. Flag anything that changed.
• Never delete or rewrite an existing entry. Need to add something? Write a labeled late entry. The incident report goes wherever your facility's policy sends it. The chart gets the clinical facts.

What goes wrong

The most common post-fall note looks like this:

Pt found on floor. No injury. Assisted back to bed. Will monitor.

Looks complete. It isn't, and the reasons are practical:

• No injury is a conclusion, not a finding. A hip fracture or a slow intracranial bleed may not show at minute five. The reader can't tell whether you checked hips, head and ROM or just glanced at the patient. If the assessment isn't written down, nobody can see it happened.
• Will monitor is a promise. Say the next four hours of charting have no neuro checks and no vitals. That gap is what readers will see.
• The chart is the only witness that lasts. The next shift, the provider, any later reviewer: all they have is what's written. You won't be in the room when they read it.

The second common mistake is filling gaps after the fact. Writing a timeline you didn't witness. Charting a post-fall assessment as if you'd been there, when you actually learned about the fall hours later. Removing a note because someone asked you to. Write what you know, when you learned it and who told you. Nothing more.

It is not hypothetical

McComb Nursing and Rehabilitation Center, LLC v. Lee — Court of Appeals of Mississippi, 2012. Opinion A resident was found on the floor on his left side, five days after admission. The plaintiff's nursing expert testified that the notes showed only one neuro check and no head-to-toe exam. The physical therapist found his hip fracture the next day. Here's the expert's opinion as the court summarized it: “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”. The jury found for the estate. The appeals court affirmed.

Montilla v. St. Luke's-Roosevelt Hospital — Appellate Division, Supreme Court of New York, 2017. Opinion A nurse found the patient on the floor. A CT later that day showed an intraventricular hemorrhage. The hospital's expert read the chart and noted it had no documentation of bleeding or external injury from a fall. The court affirmed dismissal, partly because the plaintiff's expert opinion was too speculative: “the expert failed to adduce any evidence as to what, if any, portion of decedent’s head was actually struck.” A footnote adds one more thing. The nurse's handwritten BP that morning didn't match the printed record. Where the head hit, whether your numbers match across records: that's exactly what everyone reads later.

Tinsley v. Medical Facilities of Am. XLVII, L.P. — Roanoke County Circuit Court (Virginia), 2011. Opinion A discovery ruling about incident reports, post-fall assessments and witness statements. The court held that factual documents like these weren't privileged and were discoverable, with patient identifiers removed. It also said: “While the staff policy states that these post-fall assessments should not be placed in the patients’ files, this is not dispositive of their designation.” A separate form is not a vault. Write it as carefully as you write the chart.

Varkey v. Melhem — Texas Court of Appeals, 14th District (Houston), 2022. Opinion A patient was helped to the bathroom around 5:20 a.m. About 40 minutes later he was found on the floor in cardiac arrest. The plaintiffs' physician expert built his timeline on this: “that was the last contact documented with Mr. Varkey from the nursing staff.” The appeals court affirmed dismissal because the expert reports were deficient. So this isn't a finding against the nurses. It still shows how people read a chart afterward. Your last documented contact becomes their clock.

Uriegas v. Kenmar Residential HCS Services, Inc. — Supreme Court of Texas, 2023. Opinion The resident was nonverbal. He fell in the shower, and that evening staff described him as wobbly. The next day he fell again. The day after that, a hip and femur fracture were found. Describing the alleged facts, the court wrote: “Uriegas received no medical evaluation or treatment after his second, unmonitored fall until the next day.” The court held that the expert reports were adequate and let the case go forward.

Estate of Fleenor v. Ottawa County — Ohio Court of Appeals, 2021. Opinion A shower chair tipped over with the resident in it. The record described the follow-up in detail: “The nursing staff performed regular neurological checks over the next 13 hours and completed 72-hour post-fall check sheets.” The resident died several days later. The appeals court reversed summary judgment for the nursing home and sent the case back. The lesson: after a fall, readers go through your charting entry by entry. All the way to the last note.

What to write instead

Words that do the damage

What the guidance says

• For a while after a fall, watch the patient more closely than usual. Each time, document what you checked: alertness, vitals, any change for better or worse. (AHRQ, MedlinePlus)
• The post-fall assessment has to be thorough enough to find a neuro deficit or injury. It goes in the medical record. (PMC, AHRQ)
• Document the fall the way your own facility's policy says. (MedlinePlus, PMC)
• After a fall, reassess fall risk and bleeding risk. Chart the result. (PMC, NurseChartingPro)

Copy this

Nursing note: fall or patient found on floor

``` [DATE] [TIME] Pt [FOUND ON FLOOR / OBSERVED FALLING] in [LOCATION, e.g. room beside bed / bathroom]. Witnessed: [YES - BY WHOM / NO]. Position when found: [e.g. lying on L side, supine, sitting against bed]. Environment on arrival: call light [WITHIN REACH / NOT WITHIN REACH], bed [LOW / HIGH], bed alarm [ON AND SOUNDING / ON, NOT SOUNDING / OFF], footwear [NONSKID SOCKS / BAREFOOT / SHOES], floor [DRY / WET]. Pt states: [PATIENT'S OWN WORDS ABOUT WHAT HAPPENED]. Pt [DENIES / REPORTS] hitting head.

Assessment before moving pt: VS: BP [ ], HR [ ], RR [ ], SpO2 [ ]% [RA / O2 L/MIN], T [ ], BG [ ]. Neuro: LOC [ ], oriented x[ ] (baseline x[ ]), pupils [SIZE / REACTIVITY], grips [ ], speech [ ], GCS [ ]. Head-to-toe: [FINDINGS, including negatives, e.g. no lacerations, bruising, or swelling; legs equal length, no external rotation]. ROM: [ALL EXTREMITIES / EXCEPTIONS], pain with movement [YES - WHERE / NO]. Pain: [ ]/10, location [ ]. Anticoagulant / antiplatelet on MAR: [NONE / DRUG NAME].

Pt returned to [BED / CHAIR] at [TIME] with [NUMBER] staff using [METHOD / DEVICE]. [TIME] [PROVIDER NAME] notified of fall and findings. Orders received: [ORDERS / NONE]. [TIME] [FAMILY MEMBER NAME, RELATIONSHIP] notified by [PHONE / IN PERSON / VOICEMAIL LEFT]. [TIME] [CHARGE NURSE / SUPERVISOR NAME] notified. Fall risk reassessed: [SCALE NAME] score [ ]. Interventions in place: [e.g. bed low and locked, alarm on, call light in reach, toileting schedule q2h, nonskid socks]. Neuro checks / VS per [ORDER / POLICY]: [FREQUENCY AND DURATION]. ```

Follow-up note on a later shift

`` [DATE] [TIME] Post-fall monitoring, day [ ] of [ ]. Event of [DATE OF FALL] [TIME OF FALL] per prior documentation. VS: BP [ ], HR [ ], RR [ ], SpO2 [ ]%, T [ ]. Neuro: LOC [ ], oriented x[ ] (baseline x[ ]), pupils [ ], grips [ ], speech [ ], GCS [ ]. Compared with last check at [TIME]: [UNCHANGED / CHANGED - DESCRIBE]. Site(s) of concern: [e.g. L hip - no swelling, bruising unchanged, 2 x 3 cm, purple]. Pain: [ ]/10, location [ ]. Intervention: [MED / DOSE / TIME]. Reassessed at [TIME]: [ ]/10. Mobility / ADLs compared with baseline: [SAME / DECLINED - DESCRIBE]. New findings reported to [PROVIDER NAME] at [TIME]: [FINDINGS / NONE]. Orders received: [ORDERS / NONE]. Interventions in place: [LIST]. ``

Late entry or addendum

`` [DATE] [TIME OF WRITING] LATE ENTRY for [DATE] [TIME OF EVENT]. At [TIME] writer was informed by [NAME, ROLE] that pt was [FOUND ON FLOOR / REPORTED A FALL] at approx. [TIME]. Writer did not witness the event. Writer assessed pt at [TIME]: [VS, NEURO, HEAD-TO-TOE, ROM, PAIN - AS ABOVE]. [PROVIDER NAME] notified at [TIME]. [FAMILY MEMBER] notified at [TIME]. This entry is written late because [FACTUAL REASON, e.g. writer was informed of event at start of shift]. ``

If you remember one thing

Write down what you saw and what you checked, with times and numbers. What you didn't see or didn't check stays out.

Read the decisions yourself

Every case below is a published decision on CourtListener. Open them. Nothing on this page asks you to take our word for what a court said — and where we only had the search result rather than the full opinion, it says so.

• Estate of Fleenor v. Ottawa Cty.Ohio Court of Appeals · 2021-06-30 · full opinion
• Montilla v. St. Luke's-Roosevelt HospitalAppellate Division of the Supreme Court of the State of New York · 2017-02-02 · full opinion
• McComb Nursing and Rehabilitation Center, LLC v. LeeCourt of Appeals of Mississippi · 2012-02-21 · full opinion
• Jesse Uriegas, as Guardian of Brandon Uriegas, an Incapacitated Person v. Kenmar Residential Hcs Services, Inc.Texas Supreme Court · 2023-09-15 · full opinion
• Regina Ann Varkey, Individually and as the Representative of the Estate of Anil C. Varkey, and Angelina Gina Varkey v. Dr. Ayyash, Melhem, MD Hye Jung Lee RN Tenaka M. Basile, RN And Samuel S. Dizon, RNTexas Court of Appeals, 14th District (Houston) · 2022-08-09 · full opinion
• Tinsley v. Medical Facilities of Am. XLVII, L.P.Roanoke County Circuit Court · 2011-03-31 · full opinion

All the decisions behind this guide, in one page — searchable by court, year, or what happened.

What people say on the floor

Nurses talking to each other about this, quoted as they wrote it. This is opinion, not a source. It is here because it shows what the argument actually is — the rules above come from the decisions and the published guidance, not from these threads.

• Like "parameters was not assessed immediately post fall cos the fall was not make known to us, but last parameters after the fall was done at xxx time." Patient to staff ratio can also be found (for my side, when there's a fall, we need to state patient:staff for them to analyse workl

  r/nursing on Reddit: DON asking me to write a fall report that I am unaware of reddit

• They had said that they had been made aware of the fall and were going through the documentation and was concerned that I had typed a nursing note regarding the fall. She stated that our hospital legal department had recently explained to hospital leadership that a patient had used a nursing note in

  r/nursing on Reddit: Manager asks that I remove Nursing Note from patient’s chart regardin reddit

• We now have to document two VHIMS reports - one for the fall, and one for the failure to report. Medical imaging and medical review as appropriate. That nurse gets in a LOT of trouble. ... Did the nurse not assess the patient? ROM is one of the top things you check after a fall and you document it a

  r/nursing on Reddit: What is the standard protocol for when a patient falls? reddit

• There was one night she fell five times in a 10-hour period thanks to severe muscle atrophy and delirium (neglectful SAR that discharged her while she was having an active UTI and my physical findings were the exact opposite of what they were documenting). ... From a trauma standpoint you don’t. You

  r/nursing on Reddit: Post fall assessment (see caption for question please) reddit

What everyone else says

Guidance from professional bodies, insurers and other people who write about this. Useful, but it is advice, not law — that part is above.

• Chapter 2. Fall Response | Agency for Healthcare Research and Quality ahrq.gov
• After a fall in the hospital: MedlinePlus Medical Encyclopedia medlineplus.gov
• Inpatient Falls: Improving assessment, documentation, and management - PMC pmc.ncbi.nlm.nih.gov
• When a Fall Occurs Four steps to take in response to a fall. | Article | NursingCenter nursingcenter.com
• Documenting fall episodes: a scoping review - PMC ncbi.nlm.nih.gov
• What Should I Do if a Nursing Patient Falls? 2026 northstatelawfirm.com
• Documenting Patient Falls - General Nursing Support allnurses.com
• Patient Safety Checks and Hourly Rounding Documentation | NurseChartingPro nursechartingpro.com