SHM Converge Scientific Abstract ePoster Gallery-Implementing Standardized Comprehensive Post-Fall Assessment and Documentation in the Inpatient Setting

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This project developed a standardized post-fall documentation template in the EPIC electronic medical record to improve inpatient fall assessment and management. The goal was to help providers consistently evaluate falls, support clinical decision-making, and improve patient outcomes.<br /><br />The template prompts clinicians to document key details such as the time of assessment, the circumstances and possible causes of the fall, medications that may increase fall or bleeding risk, whether head trauma occurred, and any history of dementia or cognitive impairment. It also guides a detailed physical exam, including skin, musculoskeletal, and neurological findings, and asks providers to consider the need for post-fall imaging, labs, and additional fall precautions.<br /><br />Educational sessions were provided to hospitalists, advanced practice providers, and housestaff to improve use of the template. After implementation, charts of inpatient falls on medicine wards were reviewed to measure provider compliance and examine patterns related to opioid/sedative exposure and imaging use.<br /><br />The project was based on the finding that standardized post-fall assessment is essential for timely identification of injuries, especially in an urban tertiary care center. In the units where the tool was introduced and education was delivered, there were 76 inpatient falls during the study period. The post-fall template was used in 29 cases, representing 38.2% compliance.

Asset Subtitle

Natalie Cedeno

Meta Tag

Author List Brian Markoff, Elizabeth Dauer, Ezequiel Rodriguez, Mangalore Shantheri Shenoy, Michelle Dunn, Natalie Cedeno, Surafel Tsega

Category Innovations

Concept Post-Fall Documentation Template

Concept Inpatient Fall

Concept Post-Fall Assessment Note

Concept Physical Examination

Concept Neurologic Assessment

Distinguished Non-Finalist

Presenter Organization Mount Sinai Morningside West, Icahn School of Medicine

Presenting Author Natalie Cedeno

Track Quality Improvement

Keywords

post-fall documentation

inpatient falls

EPIC electronic medical record

standardized assessment

fall management

clinical decision-making

patient safety

provider compliance

imaging use

fall risk assessment

Post-Fall Documentation Template

Inpatient Fall

Post-Fall Assessment Note

Physical Examination

Neurologic Assessment