Which documentation entry is most appropriate after a patient falls?
Correct answer: B. Patient found sitting on the floor beside the bed at 10:15 am.
- A. Patient fell because she is careless and confused.
- B. Patient found sitting on the floor beside the bed at 10:15 am.
- C. Patient had an accident and was probably frightened.
- D. Patient fell safely, so no further action was required.
Explanation
The entry records what the nurse observed, including the location and time, without assigning blame or guessing the cause. The nurse should also document assessment findings, actions taken, notifications, and the patient’s response according to policy.
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About Documentation, Reporting and Communication
Documentation covers accurate, timely and objective nursing records, charting formats, incident reports, medication records, confidentiality and legal accountability. Communication includes therapeutic listening, questioning, empathy, handover and reporting using a structured method such as SBAR, while distinguishing subjective patient statements from objective observations.
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