Question

One of your assigned clients gets up to go to the bathroom without calling you. The client falls to the floor and calls for help. You answer the call and alert your supervisor. After assuring that the vital signs are normal and there does not appear to be any injuries, you are told to fill out an incident report. In addition to noting that the client was found on the floor, which of the following statements would you most need to record in the nursing notes for the client?

1)Incident report completed.
2)The reason the client was unattended.
3)The vital signs and assessment of the client.
4)Location of the incident report.

Answer 1

You should record the vital signs and assessment of the client after a fall, as it is the most important information needed for ongoing patient care and for legal documentation.

Step-by-step explanation:

When documenting an incident where a client falls, it is imperative to include detailed information about the assessment of the client after the fall. Therefore, among the options provided, you would most need to record the vital signs and the assessment of the client. This documentation should include any observations made about the client's condition, the assistance provided, and the outcomes of any immediate interventions. It's crucial to ensure that the details in the nursing notes are accurate and complete, as this information can be critical for ongoing patient care and for legal reasons.

In addition to noting the client's vital signs and assessment, one should ensure that the broader context and any actions taken by the healthcare team are well-documented. This ensures a thorough record and facilitates communication among the healthcare providers.