Policy Manual sample

MDT Home Health Care Agency, Inc. 16. Taking any medication that could have contributed to fall/accident? 17. Patient’’s mental status? Oriented Confused Depressed Irrational/Agitated 18. What was the possible cause? Muscular/Skeletal Unsteady gait Faint/Dizzy Tripped Not using assistive device Cognitive Impairment Medications Acute Illness Other BP On what Explain 19. Incident Report completed? Most recent OASIS (Fall): ___________________________________________________ Additional comments: _________________________________________________________ Completed By: _______________________________________________________________ Signature: _________________________________ Date: _____________________________ Home Health Agency Nursing Care & Procedures K-128