Emergency Room Fall Incident Assessment
Date of Incident
Time of Incident
Location
Patient Name
Patient ID
Age
Witness(es) Name(s)
Staff Involved
Description of Fall
Location Where Patient Was Found
Activity at Time of Fall
Was the fall observed?
Yes
No
If yes, by whom?
Environmental Factors
Injury Assessment
Was there an injury?
Yes
No
If yes, describe injury
Actions Taken
Physician Notified?
Yes
No
Family/Representative Notified?
Yes
No
Additional Notes