Implementation of 24-Hour Post-Fall Note

Premier Nursing News     March 2019

Premier Health’s Moving Safely Committee has collaborated with Nursing Shared Governance and the Informatics Team to develop a 24-Hour Post-Fall note. The National Database of Nursing Quality Indicators (NDNQI) requires us to report the presence and level of any injury at the time of the fall, or up to 24 hours after the fall if waiting on imaging results. This allows time for redness and abrasions that might be present at the time of fall, but not at 24 hours, to be eliminated from the injury data, providing for a more complete assessment. With current documentation, it is difficult to determine the true consequences of the fall.

The 24-Hour Post-Fall note can be found in EPIC by typing “fall” into the smart text box. The process of our current post fall note does not change. This 24-Hour Post-Fall note is an additional note and should be filed as an intervention note. Utilizing this note will ensure consistency and complete reassessment for injury at 24 hours. Each facility has determined who is responsible for completing the new note.

The post-fall note should be completed around the 24-hour mark, preferably not too long before or after. If a patient is discharged before completion of the 24-Hour Post-Fall note, the note must be completed at the time of discharge and should report what the injury was at the time of discharge. At Atrium Medical Center, the process for the note varies by unit. At Miami Valley Hospital, the Acute Changes Team (ACT) nurse will call in a reminder to the unit during the shift that the 24-Hour Post-Fall note is due. At Upper Valley Medical Center, a note will be placed on the communication board at the nurse’s station indicating that a 24-Hour Post-Fall note is due on a patient within the next 24 hours. This should also be shared during the end-of-shift hand-off.

The Atrium Medical Center Moving Safely Committee representative is Emilee Bird, MS, RN, APRN, ACNS-BC. She can be reached at (513) 974-5197(513) 974-5197.

The Miami Valley Hospital Moving Safely Committee representative is Stephanie Hisey, MS, APRN, AGCNS-BC, OCN. She can be reached at (937) 208-3502(937) 208-3502 .

The Upper Valley Medical Center Moving Safely Committee representative is Sarah Jones, MS, APRN, ACNS-BC, AOCNS, VA-BC. She can be reached at (937) 440-4827(937) 440-4827 .

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