Name of the Procedure:

Patient Experienced a Fall Documentation (HCPCS Code: G8910)

Common Name(s): Fall Documentation, Fall Evaluation
Technical/Medical Term: Patient Fall Reporting within Ambulatory Surgery Center (ASC)

Summary

This procedure involves the documentation and evaluation of a patient who has experienced a fall within an ambulatory surgery center (ASC). The healthcare team records the details of the incident, assesses the patient’s condition, and takes necessary actions to prevent further complications.

Purpose

Medical Conditions/Problems Addressed:

• Assessing injuries resulting from the fall
• Providing immediate care if needed
• Identifying and addressing fall risk factors

Goals/Expected Outcomes:

• Ensure patient safety
• Prevent future falls
• Document the incident for medical and legal records

Indications

Symptoms/Conditions Warranting the Procedure:

• Any patient who has experienced a fall within an ASC

Patient Criteria/Factors:

• All patients who report or are witnessed having had a fall in the facility

Preparation

Pre-Procedure Instructions:

• None specifically as it happens post-fall

Diagnostic Tests/Assessments Required:

• Vital signs check
• Physical examination for injuries
• Neurological assessment if head injury is suspected

Procedure Description

1. Immediate Response:

   • Ensure patient is safe and assess for immediate injuries
   • Call for assistance if needed

2. Assessment:

   • Conduct a thorough physical examination
   • Check vital signs (blood pressure, heart rate, etc.)
   • Perform neurological assessment if head trauma is suspected

3. Documentation:

   • Record fall circumstances (time, location, activity during fall)
   • Note any apparent injuries and immediate interventions provided
   • Document findings from assessments

4. Post-Fall Plan:

   • Develop a care plan to address injuries
   • Implement fall prevention strategies

Tools/Equipment Used:

• Blood pressure monitor
• Stethoscope
• Neurological assessment tools

Anesthesia/Sedation:

• Not typically required unless emergency treatment is necessary

Duration

The documentation and initial assessment typically take 30-60 minutes, depending on the severity of the fall and injuries.

Setting

Performed within any area of the ambulatory surgery center where the fall occurred.

Personnel

• Nurses
• Physicians or Surgeons
• Assistive staff (e.g., medical assistants, physical therapists if needed)

Risks and Complications

Common Risks:

• Further injury if fall is not adequately managed

Rare Risks:

• Misdiagnosis of injury severity
• Delayed detection of complications (e.g., internal bleeding, subdural hematoma)

Possible Complications:

• Secondary falls
• Complications from unaddressed injuries

Benefits

• Immediate assessment and care reduce the risk of further injury
• Enhanced patient safety through quick intervention
• Proper documentation for ongoing medical management

Recovery

Post-Procedure Care:

• Continued monitoring for delayed symptoms
• Pain management if required
• Instructions on activity limitations or adaptations

Expected Recovery Time:

• Varies by injury; minor falls may need minimal time, while serious injuries require longer recovery.

Follow-Up:

• Scheduled follow-up appointments to monitor recovery and assess fall prevention needs

Alternatives

Other Treatment Options:

• Not applicable as this is an assessment and documentation process

Pros and Cons of Alternatives:

• No true alternatives exist as this is a necessary evaluative step post-fall

Patient Experience

During the Procedure:

• Patients may feel anxious or embarrassed; staff should provide reassurance and comfort

After the Procedure:

• Patients may experience soreness depending on the fall; pain will be managed as needed
• Instructions will be provided for safe recovery and fall prevention