Recording, review and learning

A fall does not end when the person is back in bed or the paperwork is filed. Clear recording and timely review show what changed, what action is needed, and how to reduce the chance of it happening again.

Good review looks at the complete picture: what the person was doing, recent changes in health or medication, the environment, whether a walking aid was available, any urgency or dizziness, and whether the current support plan remains appropriate.

What good recording should include

• Facts of the event: time, place, who found the person, whether it was witnessed, and what the person said.
• Condition and immediate response: pain, obvious injury, help called, observations or checks completed, and how the person was assisted.
• Context: route, footwear, aid availability, lighting, urgency, recent illness, medicine changes or recent discharge.
• What changed next: plan review, family contact, clinical advice, environmental action or monitoring agreed.
• Patterns: whether this links to previous near misses, repeated night-time events or the same trigger.

Manager focus: trend review and governance

Record enough detail that the next person can learn from the fall, not just count it.