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Q&A: A medical records consultant suggested that I should complete a fall investigation worksheet form on paper after every fall to keep in my office. Is this common practice?

Question: I am a new DON.  I have a medical records consultant here today who suggested that I should be completing a fall investigation worksheet form on paper to keep in my office after every fall in addition to the record in the patient’s chart and electronic medical record.  We have been using EMR for several years and I cringe at the thought of adding a paper worksheet. I am just curious if this is common practice for other DONs?


Deborah Green, RN, DNS-CT, RAC-CT, offered:

We have used a fall packet to investigate falls for years. It contains a statement regarding the state of the resident and environment at the time of the fall, witness statements from any witnesses, a short-term plan of care addressing the fall, any interventions put into place to prevent further falls, the CAA regarding falls to assist staff in problem solving the fall, a neurological check, a post-fall assessment sheet, and vitals for each shift for three days. We save these hard copies as a QA tool for ten years. We also load them into our electronic incident reporting tool including our follow-up as a QA/risk manager tool. If you are associated with a hospital system, you may want to reach out to your risk manager or if you are a stand-alone facility, you may want to reach out to your insurance company risk manager to help you in this area. Hope this helps.

Patricia Ward, BSN, NHA, RN, RAC- CT added:

My experience as a DON and a LHCRM has always been that the post-fall documentation begins with the first responder. That person documents what he/she sees when they arrive on the scene and what the person tells them.  The nurse then evaluates the person and follows procedure. The post-fall report, along with the incidence/occurrence report, is forwarded to the Risk Manager.​  I have always maintained the post-fall investigation forms in my office under lock.  My form has a statement on it that this is work product and covered under QA&A. I have always relied on the Risk Manager to complete the fishbone analysis of the fall. I am available to assist.

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