RN Nursing · Client Safety · Practice question
A nurse is caring for a client who has fallen while getting out of bed... After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record?
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✓
"The provider was notified."
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"An incident report was forwarded to risk management."
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"There were no injuries sustained."
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"An incident report was completed."
Answer & explanation
Correct: "The provider was notified."
When a client fall occurs, the nurse's medical record documentation should focus on objective clinical facts: what was observed, what assessments were performed, what actions were taken, and who was notified. Stating that the provider was notified is an appropriate and legally significant clinical entry because it documents the chain of communication and shows that appropriate escalation occurred after the event. Documenting that an incident report was forwarded to risk management or that an incident report was completed is specifically prohibited from the medical record — incident reports are internal quality-improvement documents and are legally privileged; referencing them in the chart can destroy that privilege and expose the facility to liability. Stating that there were no injuries sustained could be premature and inaccurate because some injuries, such as a subdural hematoma, may not be immediately apparent, making this documentation potentially misleading and incorrect. Therefore, noting provider notification is the most appropriate entry among the choices given.
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