RN Incident and Fall Notes

[text name="variable_1" default="Date of Incident"]  at [text name="variable_2" default="Time of call"]. Reported by unit nurse, resident found [checkbox name="TYPE" value="sitting on the floor|lying on the floor"] [textarea name="variable_1" default="other details"].at [text name="variable_3" default="Time of Incident"]. 

Resident was immediately assessed by the nurse and nursing supervisor and safely assisted back to bed. Resident, alert and oriented x [text size="5"], [textarea name="variable_1" default="other details of mental status"]. No changes in mental status/LOC observed.


Vital signs taken
Lying Blood Pressure: [text size="5" default="  /"] mmHg
Sitting Blood Pressure: [text size="5" default="  /"] mmHg
Pulse: [text size="5"] BPM
Temperature: T [text size="5"] F
Respiration: R [text size="5"]
Oxygen Saturation: O2 [text size="5"] via room air
Blood Sugar: [text size="5"]mg/dl

Assessment
[textarea cols=80 rows=2 default="GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress."]
[textarea cols=80 rows=3 default="CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits."]
[textarea cols=80 rows=1 default="RESPIRATORY: no cough/sputum/SOB/chest pain. LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds."]
[textarea cols=80 rows=1 default="GENITOURINARY: no dysuria/frequency/blood in urine/incontinence"]
[textarea cols=80 rows=1 default="GASTROINTESTINAL: no constipation/diarrhea/blood in stool/melena.Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses."]
[textarea cols=80 rows=2 default="MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait."]
[textarea cols=80 rows=1 default="SKIN: Skin normal color, texture and turgor with no lesions or eruptions, no rashes, bruising, nail or hair changes."] 


[text size="20"] [checkbox value="notified of the incident via phone|notified of the incident via voice message"] . [text size="6"] was made aware that resident will be [text size="20"] and agreed on the plan.

Incident referred to Dr. [text size="6"] and ordered to [textarea name="variable_3" default=ORDERS]

PT/OT evaluation due to s/p FALL. Resident rea-assessed every 30 minutes and observe to be lying comfortably without any visual s/s of pain. Resident placed on NEUROCHECK every 4 hours for 3 days. Resident was educated and will be reminded and encouraged to use call bell to call staff for assistance anytime assistance is needed and not to attempt unsafe self-transfer or self-ambulate in order to avoid future fall/incident. Resident verbalized understanding. Yellow charm was placed on resident ID bracelet to alert staff that resident is at risk for falls and should be closely monitored. Resident was provided with bed alarm as additional safety measure.

at . Reported by unit nurse, resident found
.at .

Resident was immediately assessed by the nurse and nursing supervisor and safely assisted back to bed. Resident, alert and oriented x ,
. No changes in mental status/LOC observed.


Vital signs taken
Lying Blood Pressure: mmHg
Sitting Blood Pressure: mmHg
Pulse: BPM
Temperature: T F
Respiration: R
Oxygen Saturation: O2 via room air
Blood Sugar: mg/dl

Assessment









. was made aware that resident will be and agreed on the plan.

Incident referred to Dr. and ordered to


PT/OT evaluation due to s/p FALL. Resident rea-assessed every 30 minutes and observe to be lying comfortably without any visual s/s of pain. Resident placed on NEUROCHECK every 4 hours for 3 days. Resident was educated and will be reminded and encouraged to use call bell to call staff for assistance anytime assistance is needed and not to attempt unsafe self-transfer or self-ambulate in order to avoid future fall/incident. Resident verbalized understanding. Yellow charm was placed on resident ID bracelet to alert staff that resident is at risk for falls and should be closely monitored. Resident was provided with bed alarm as additional safety measure.

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