Patient Safety Risk Management Documentation Guidelines

Patient safety is an important part of the health care system. Prevention of injury is important and certain measures are put into place to help eliminate patient injury while they are receiving treatment at health care facilities. Accidents do occur and when injury results, the incident should be properly documented in the patient's chart.

When patient injuries occur due to a fall

• When a patient becomes injured in a health care facility, the health care provider must offer documentation to account for the incident which led to the injury. Falls, skin tears, and bruises are an example of injuries that should be documented. Falls can result in a wide array of injuries such as bruises, broken bones, and lacerations. When a patient falls it is important to write when, where and how the fall occurred. Describe the incident accurately and give as many details as possible. Include all safety precautions used in order to prevent the fall and explain why the precautions failed to work properly.

Bruising found on a patient

• Each patient is given a physical exam upon entering a health care facility. The physical condition of each patient is recorded in their chart and can be used as a baseline reference. If a health care provider notices a bruise on the patient's body, it must be documented. Elderly people tend to bruise easily due to various medical conditions and medications. All bruises should be documented in the patient's medical record with the description of the size, location, and color of the bruise. Also, document how the bruise occurred, if known. For example, drawing blood from a patient may result in bruising and should be documented.

Skin tear injuries

• Patients may get skin tears, which refers to a rip in the patient’s skin. Skin tears are common among the elderly due to the loss of elasticity, muscle and fat layers under the skin. This results in the patient having what is referred to as "thin skin" which tends to rip and tear easily. "Thin skin" may cause the patient’s skin to tear when not properly handled and can also occur even when the skin is handled in a gentle manner. Sliding a patient up without lifting the patient from the bed can result in skin tears on the back. Pulling on the skin of the arms while trying to dress a patient may result in skin tears on the arms. Skin tears should be documented in the patient’s chart. Describe the size, location and cause of the tear, when known.

Safety precautions used to avoid injury

• Each health care facility has in place a patient safety policy and procedure plan. Bed rails, patient activity alarms, wheel chair locks and skin protectors are used to help avoid patient injuries. It is important to document all safety precautions used for a patient when documenting patient injuries. If the patient has bed rails and fell because he/she became confused and tried to climb over them, it is important to document that the rails were up in place on both sides of the bed and describe what happened in as much detail as possible.