Fall Incident Report Form printable pdf download

FALL INCIDENT REPORT

(This tool is only an example. Please adapt it to meet the needs of your facility and residents.)

MR # _________ Last Name ______________________ First Name ______________ Room # _____

Date ______________ Time _____________ am/pm

□ Resident

□ Employee

□ Visitor

Type of Incident (Check):

□ Fall

□ Behavior

□ Other (Specify):

______________________________________________________________________________________

Physical Assessment:

If fall what position was person found in? (Describe in detail): _________________________________

______________________________________________________________________________________

Describe mobility or range-of-motion of extremities following incident: _________________________

______________________________________________________________________________________

Is assessed mobility or range-of-motion ability a change? (Check): □ No

□ Yes (Describe): _______

______________________________________________________________________________________

Injury (Check): □ None □ Laceration □ Skin Tear □ Abrasion □ Hematoma □ Swelling □ Other

(Describe and Locate on Diagram): _________________________________________________________

________________________

_____________________

Vital Signs:

Other:

B/P Lie _____ Temp ______

BG Accu Check________

B/P Sit _____ Pulse _______

Pulse Oximetry ________

B/P Stand ___ Resp _______

Neuro Checks _________

Treatment (Check All That Apply)

□ Examined at Hospital: _______________________ □ Admitted to Hospital: _____________________

□ Xray Done (Results): ________________________ □ First Aid Administered: ___________________

______________________________________________________________________________________

Name of Person(s) Administering Treatment: ______________________________________________

Physician Notified: _____________________ Time: ______ am/pm Response Time: ______ am\pm

Family/Other Notified: __________________ Time: ______ am/pm Response Time: ______am/pm

(Complete Reverse at the Time of Incident)

KDOA Workgroup05

Fall Incident Report Form