After a client falls, which documentation is appropriate in the medical record?

Question

Accepted Answer

B. “Client found on floor; assisted to bed; vital signs obtained; provider notified.” — Document objective facts and assessments in the chart. Incident reports are completed per policy but are not documented in the medical record; avoid blame or subjective statements.

Answer

A. “Incident report completed.”

Answer

C. “Fall occurred due to staff negligence.”

Answer

D. “No charting is needed if the client seems fine.”