NOTATION OF PREVIOUS FALLS IN ADMISSION RECORD OF HOSPITALIZED ELDERLY

To test the hypothesis that a history of falling is underreported by p hysicians and nurses, we assessed the extent to which previous falls a re noted in the admission medical history. A total of 168 community-dw elling and institutionalized elderly adults, greater than or equal to 70 years old, were evaluated in the emergency ward of a tertiary care community-based teaching hospital, and admitted to a general medical w ard. Physicians' and nurses' emergency ward and admission notes were r eviewed for the inclusion of ''falls.'' Within 72 hours of admission, the information provided or omitted in the medical record was confirme d or refuted by face-to-face interview. Follow-up data were gleaned fr om computer-based records. The sample population consisted of 113 pati ents, 56% female, with a mean age of 80.7. Seventy-six patients had fa llen within the past 10 years; of these, 32 (42%) were Recent Fallers, and 44 (58%) were Multiple Fallers. Review of the medical records rev ealed 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 (6 4%) of the Multiple Fallers were missed. Examination of the nursing no tes 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.