Accuracy Of Patient Recall And Chart Documentation Of Falls

Abstract

Background: This 1-year prospective study examined the accuracy of patient recall of falls and fall injuries and completeness of chart documentation of these events.

Methods: One hundred ambulatory geriatric family practice patients reported falls weekly by postcard with telephone call follow-up. On a final postcard they reported their recall of falls and fall injuries in the preceding 3-, 6-, and 12-month periods. Patient charts were reviewed for fall documentation.

Results: For the 3-, 6-, and 12-month periods, respectively, 31 percent, 44 percent, and 89 percent of participants who had reported a fall recalled at least one fall. Sixty-eight percent of participants who had reported an injury recalled one at the year’s end. The positive predictive value of recalling a fall was 92 percent and of recalling a fall injury was 72 percent for the 1-year period. Only 10 of 56 (18 percent) reported falls were documented in the patient’s chart.

Conclusions: Patients recalled falls and injuries in the previous 12 months well, but they were less accurate for recall periods of 3 and 6 months. Few reported falls were documented by the patient’s physician. Awareness of falls can be increased by asking the patient about falls during the previous year and by documenting all reported and recalled falls.