Question

Mr. stan was born on 12th May 1945, You are the nurse looking after Stan and he had a fall and has injured his head, whom do you report and how would you document in progress notes. (Use organization policies how do you write in the progress notes). Is it mandatory to report a fall?

Answer 1

It is mandatory to report a fall. An incident report has to be filled in and to be sent to the concerned authority as per the policy .It has to be reported to the nurse incharge, nurse supervisor and to be documented in nurses notes and to be informed to the concerned provider and documented on progress notes.

To write in the progress notes the following things are mandatory like date and time of call, provider name, description of the incident and patient condition or status and signature of the nurse with designation.

SOAP notes can be followed to document

Subjective:Patient has an injury to head first to fall

Objective :Mr. Stan a babyboomer had a fall today and injured his head. Other parameters within normal limits

Assessment :Injury to head is noted

Recomendation: I would recommend for an analgesic go manage pain and the provider visit for further evaluation and treatment .