Top to Toe Assessment
A top to toe assessment should be carried out by staff to confirm signs of injury following a fall. This assessment should be documented in full in the patients’ unitary notes.
An example of what this looks like on TRAK is below:
As good practice, please follow the post fall bundle summary:
Post fall bundle
- Assess for signs and symptoms of fracture or potential spinal injury before the patient is moved
- Safe manual handling methods for patients with signs and symptoms of fracture or potential for spinal injury
- Frequency and duration of neurological observations for all patients where head injury has occurred or cannot be excluded (e.g. un-witnessed falls) based on guidance
- Adhere to agreed timescales for medical examination following a fall or high vulnerability to injury, or who have been immobilised
- Conduct a post fall review / rapid root cause analysis (to learn how further falls can be prevented for the patient and annotate during report of incident for wider learning).
Datix
All staff must ensure that the Incident Management Policy is followed and the incident recorded on DATIX, ensuring that the rating of severity of harm follows the definitions as defined in the policy.
Information on how to raise a Datix can be found here.
