The nurse knows the following items should be included in the documentation of the patient on falls precautions: (Select all that apply.)
A) History of any falls
B) Falls risk assessment scores
C) Patient and family education
D) Use of assist devices
E) Any fall or reported fall
F) None of the above

Question

Quizplus · Accepted Answer

The nurse should document the general assessment, include the patient's medical history, subjective and objective data, medication review, musculoskeletal status, and history of falls. Falls assessment and reassessment, patient family education and use of assist devices is also documented. Thoroughly document a fall or reported fall, but do not document that an incident report has been filed in the medical record.

The Nurse Knows the Following Items Should Be Included in the Documentation