Proper record keeping and documentation are very essential when you are operating a long-term care facility. It is mandated that you should keep a record of all the medical care given to the residents in your facility, including sickness and injuries that may be sustained by them. When dealing with the elderly, falls are a common occurrence. These should be carefully and properly documented. These are documents that you will need in case of legal issues that may occur later. Make sure that your long-term care facility safe and ideally equipped for patients requiring long-term care and for the elderly. Falls can occur anytime with the elderly through no fault of your staff or your facility.
Here are tips on how to document falls in long-term care.
- Keep a detailed record of the fall. State the time, date and the exact location and how the fall occurred. Include the resident’s name and medical condition in the record. Notify the resident’s guardian or family member about the fall. Include the time, date and the person you talked with when you made the call to the resident’s family or guardian. Note down the gist of your conversation and what their instructions, comments and requests.
- There may be some witnesses within the facility such as other staff members, fellow residents and visitors. Be sure to get their full account of the incident and put them in writing. Get their names and include those in your record. Ask the witnesses to sign and date the recorded account of the incident.
- Add a detailed report of the treatments the resident had received on account of the fall. Include even minor details. Have the resident checked by a medical professional even if the fall is very minor and there are no visual signs of injury or damage. The medical professional can make a detailed assessment on the condition of the facility resident. Include the medical findings and recommended treatment in the record. The doctor should also sign and date the findings.
- Have your records checked by your facility lawyer. Every record should be legally binding and conform to regulations in the operation of a long-term care facility. You can use these documents and records as concrete evidence that you have provided the right amount of care to a resident in case a family member or the resident decides to sue you later for not providing adequate care and treatment as a result of the fall.
- Furnish a copy of all your documents in the resident’s medical file. You should also send a copy to the family member or guardian on record. Furnish them with your name and contact information. Keep the original copy with your other facility documents, properly labeled.
Ensure that your long-term care facility is a safe environment for all residents. Avoid hazards that can impede the mobility of residents and provide railing and support in critical areas such as bathrooms and toilets and in some fixtures like beds. Keeping everything documented will help keep you from getting entangled in legal issues.