Capture the risk profile on admission and per policy, and — after any fall — a complete post-fall workup:
Risk factors: fall history, gait/balance, cognition, orthostasis, sensory deficits, medications (sedatives, antihypertensives, anticoagulants), continence/toileting needs, devices, and environment.
Post-fall: witnessed vs unwitnessed; a head-to-toe injury survey; neuro checks per protocol (extended and more frequent on anticoagulation); vital signs including orthostatics; pain; and range-of-motion / weight-bearing ability.
What changed and what new intervention prevents recurrence (the root-cause element).
MDS-supportive data
Falls in the look-back and any fall with injury are coded in MDS Section J (J1700–J1900); the record must document each fall event and its injury level so the coding is supported. Function change after a fall flows to Section GG; anticoagulant use to Section N.
