Fall / Post-Fall Nursing Note Example
A post-fall note documents the facts of a fall in the clinical record: what was observed or known, assessment findings, actions performed, notifications made and follow-up.
Educational use & privacy
Educational documentation practice only. Use fictional or instructor-provided information. Do not enter real patient information or protected health information (PHI). Documentation requirements vary by organization, setting, role, policy, and applicable law.
Nursing Notes Privacy & SafetyContent status: Draft — not yet professionally reviewed.
Why it is structured this way
After a fall, the clinical record should give an objective, factual account. Readers need to know what was actually seen versus what the patient reported, what was assessed, and how the patient was monitored afterward.
When this may be used
- After a fall or a found-on-floor event.
- Documentation requirements, frequency and screens vary by organization, setting and EHR. Follow your program's and facility's policy.
Incident reports
Incident- or safety-event reporting procedures vary by organization. Follow your facility's policy about whether, where and how an incident report is completed, and about what the clinical record should say about it. This page does not tell you to reference an incident report in the clinical record.
Facts, not assumptions
Write what you saw and what the patient said. If you did not see the fall, do not describe it as if you did.
Components
Circumstances
What is known.
What belongs here
- What you observed; patient statements in quotes; where the patient was found
What does not belong
- Guesses about how the fall happened
Assessment
Findings.
What belongs here
- Findings actually obtained
What does not belong
- Unassessed findings
Actions
Care.
What belongs here
- Interventions actually performed
What does not belong
- Blame or opinions
Notifications
Communication.
What belongs here
- Who was notified and when
What does not belong
- Notifications not made
Follow-up
Monitoring.
What belongs here
- Reassessments performed per order or policy
What does not belong
- Assumed outcomes
Short fictional example
- Narrative
- 0340: Patient found sitting on floor beside bed. Patient states "I slipped trying to get to the bathroom." Alert and oriented ×4. No visible injury noted.
More detailed fictional example
- Circumstances
- 0340: Heard call from room; patient found sitting on floor beside bed, back against bed frame. Fall not witnessed. Patient states "I slipped trying to get to the bathroom. I didn't hit my head."
- Assessment
- Alert and oriented ×4. Moves all extremities. Patient reports right hip pain 3/10. 2 cm reddened area on right elbow; skin intact. Blood pressure 124/78, heart rate 88.
- Actions
- Assisted back to bed with two staff members using mechanical lift per unit policy. Bed in low position, call light within reach.
- Notifications
- 0355: Provider notified by phone of fall and findings; order received for right hip X-ray, read back. 0400: Charge nurse notified.
- Follow-up
- 0440: Neurological checks per unit post-fall protocol; alert and oriented ×4. Patient rates hip pain 3/10.
Annotated example
Notes on the detailed example above:
Fall not witnessed.
— The note is honest about what the nurse did not see.Patient states "I slipped…"
— The patient's account is quoted, not restated as fact.per unit post-fall protocol
— Follow-up actions come from existing protocol in the scenario.
Common mistakes
- Writing "patient fell" as if observed when it was not.
- Blaming staff or the patient.
- Referencing an incident report contrary to facility policy.
- Leaving out follow-up assessments.
Good vs poor documentation
Weaker (fictional)
Patient fell out of bed because she didn't listen.
Stronger (fictional)
0340: Patient found sitting on floor beside bed; fall not witnessed. Patient states "I slipped trying to get to the bathroom."
Why: Objective, factual and without blame.
Blank educational template
Fall / post-fall note: Clinical-record facts only; follow facility policy for incident reporting. Prompts only; nothing is prefilled.
- Circumstances
- [What was observed or known; patient statements in quotes]
- Assessment findings
- [Findings actually obtained]
- Actions performed
- [Interventions actually performed]
- Notifications made
- [Who was notified and when]
- Response / follow-up
- [Reassessment and ongoing monitoring]
Practice this format
- Practice Note Builder — write a practice note from a fictional scenario.
- Documentation practice questions
Related documentation guides
- Change in condition
- Provider notification
- Documentation do's and don'ts
- NCLEX Safety review — Fall prevention concepts.
Sources
- ANA's Principles for Nursing Documentation (2010) — American Nurses Association.
- Nursing Fundamentals 2e — 2.5 Documentation — Open RN (Chippewa Valley Technical College).
- Fundamentals of Nursing — 14.5 Guidelines for Effective Documentation — OpenStax.
All examples on this page are original and fictional. Sources are used to check principles; they do not endorse Dosage Calcs. See Privacy & Safety.