The nurse is doing hourly rounds when he finds a 73-year-old female client unconscious on the floor next to the bed. An incident report must be filled out. What is the best statement for the nurse to write on the incident report?
Client fell out of bed at some point between 0700 and 0800.”
“Client was found unresponsive on floor next to the bed.”
“Client likely slipped on the floor and hit her head.”
“Client attempted to ambulate without assistance and fell.”
Number 2 is correct.
The incident report should include only factual information, nothing that adds to the story, makes assumptions, or speculates as to what occurred. If the nurse did not witness the other scenarios, he should not allege or assume they occurred.