Providers can use the following format to track residents' falls and update the plan of care. * Injury Codes Resident's Name _________________ Medical Record #______________ Source: Joanne Rader, RN, MN, FAAN. Used by permission.
0 = None (no injury)
1 = Minor - no Tx required (bumps, bruises)
2 = Moderate (requires some interventions and/or physician order but not physician intervention, such as abrasions, skin tears, lacerations, treated in-house or X-ray that was negative)
3 = Severe (requires intervention and physician input and/or intervention, e.g., fracture, sprain, concussion, subdural hematoma, sutures, physician office visits, trip to emergency room and/or hospitalization)