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Addressing documentation deficiencies in emergency department records: Implications for fall risk assessment and holistic care in older adults

Year: 2025
Type: article
Study design: Observational Study
Abstract: BACKGROUND: Falls are a substantial threat to public health globally and the leading cause of unintentional injury and death among individuals aged 65 years and older. This study aimed to review the medical records of older patients in an ED after an accidental fall to summarize their documented care process and identify factors associated with hospitalization or discharge to home. METHODS: A retrospective review of medical records (n = 778) was conducted at a university hospital emergency department (ED) in Sweden. Descriptive statistics were used to report patient characteristics and differences in proportions based on information sources, the patient's inability to state the reason for the fall, and health- care interventions. RESULTS: The medical records documentation of all professionals focused on medical conditions but lacked information on social background, screening, and status in the ED. Being discharged after a fall accident (55%) was more common than being hospitalized (45%), and most hospitalizations were attributed to medical reasons. There were differences in documentation between hospitalized and discharged. Overall, the medical records of the hospitalized group had more information of patient's social situations and walking aids than the discharged group. CONCLUSION: The results highlight deficiencies in documenting critical patient information within ED medical records. These gaps in medical records hinder the effective assessment and management of fall risk in older adults. Therefore, implementing person-centered care (PCC) with a holistic approach along with fall prevention is essential.
DOI: 10.1016/j.ienj.2025.101617
Language: English
Open Access status: hybrid
Estimated APC paid: $2,900
OpenAlex ID: W4410360730
FWCI:
Cites: 34
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Related to: 10