Notation of previous falls in admission record of hospitalized elderly

To test the hypothesis that a history of falling is underreported by physicians and nurses, we assessed the extent to which previous falls are noted in the admission medical history. A total of 168 community-dwelling and institutionalized elderly adults, > or = 70 years old, were evaluated in the emergency ward of a tertiary care community-based teaching hospital, and admitted to a general medical ward. Physicians' and nurses' emergency ward and admission notes were reviewed for the inclusion of "falls." Within 72 hours of admission, the information provided or omitted in the medical record was confirmed or refuted by face-to-face interview. Follow-up data were gleaned from computer-based records. The sample population consisted of 113 patients, 56% female, with a mean age of 80.7. Seventy-six patients had fallen within the past 10 years: of these, 32 (42%) were Recent Fallers, and 44 (58%) were Multiple Fallers. Review of the medical records revealed that 56 (74%) of the 76 Fallers were not noted to have fallen by the medical staff. Moreover, 15 (47%) of the Recent Fallers and 28 (64%) of the Multiple Fallers were missed. Examination of the nursing notes yielded similar results. In conclusion, elderly patients fall more frequently than recognized. Physicians and/or nurses should include a question regarding falls as part of the routine medical history.