Post Fall Medical Assessment
Because the patient is allowed to have delirium, but we're not.
🕰️
Details of fall
Witnessed / Unwitnessed
Select
Witnessed
Unwitnessed
Head-strike
Select
No head-strike
With head-strike
Unclear if head-strike
Preceding symptoms
🩸
Coagulopathy
Anticoagulants / antiplatelets
🩺
Examination
Observations
Cervical spine
GCS / 4AT
Cranial nerves
Upper limb neuro
Lower limb neuro
🦴
External injury
Head / facial bones / neck
Thoracic / lumbar spine
Shoulders
Elbows
Wrists
Pelvis / hip / sacrum
Knees
Ankles
Able to walk pain free?
Select
Able to walk pain free
Unable to walk pain free
Not assessed
Chest
Abdomen
📋
Impression & plan
Cause(s) of fall
Post fall pathway
Select
Unwitnessed fall
Witnessed fall with head strike
Fall on anticoags/antiplatelets
Witnessed fall no head strike
Mobility / spinal precautions
Select
Able to mobilise
Spinal precautions
Awaiting further assessment prior to mobilisation
Investigations requested
CT Brain
CT C-spine
X-rays
Blood tests
ECG
MSU
Postural BP
Telemetry
CT Guidelines - Page 9/10
Additional investigations
Management plan
Analgesia
Neuro observations
Falls precautions
Physiotherapy review
Medication review
Senior medical review
Spinal precautions
Delirium prevention/management
Family/NOK updated
Additional plan