Comprehensive HPI for a Mechanical Fall
A thorough history of present illness for a patient with a mechanical fall should include specific details about the circumstances of the fall, risk factors, and potential injuries to guide appropriate management and prevention of future falls. 1
Essential Components of the HPI
Fall Circumstances
- Location and cause of fall (exact environmental factors involved)
- Time of day the fall occurred
- Activity during fall (standing, transferring, getting out of bed)
- Direction of fall
- Time spent on floor or ground after falling
- Whether the patient was able to get up independently
- Use of assistive devices at time of fall
- Footwear worn during the fall
- Presence of witnesses
Associated Symptoms
- Loss of consciousness or altered mental status before, during, or after fall
- Dizziness, lightheadedness, or vertigo
- Near-syncope or syncope
- Palpitations or chest pain
- Weakness or numbness
- Visual disturbances
- Confusion
Risk Assessment Factors
- Age (particularly if over 65)
- History of previous falls in the past year
- Difficulty with gait and/or balance
- Orthostatic symptoms
- Melena or other bleeding concerns
- Alcohol use before or at time of fall
Medical History Review
- Specific comorbidities that increase fall risk:
- Dementia
- Parkinson's disease
- Prior stroke
- Diabetes
- Previous hip fracture
- Depression
- Visual impairments
- Peripheral neuropathies
Medication Review
- Complete list of current medications with special attention to:
- Vasodilators
- Diuretics
- Antipsychotics
- Sedative/hypnotics
- Anticoagulants or antiplatelets
Functional Assessment
- Baseline mobility status
- Activities of daily living capabilities
- Use of assistive devices
- Home environment (stairs, lighting, trip hazards)
Documentation Example
"85-year-old female with history of hypertension, osteoarthritis, and mild cognitive impairment presents after falling in her bathroom at home this morning at approximately 8:30 AM. Patient reports she was transferring from toilet to sink when she tripped over the bathroom rug. She fell forward, catching herself with outstretched hands. No loss of consciousness before, during, or after the fall. No dizziness, lightheadedness, chest pain, or palpitations. Patient was able to get up independently after approximately 2 minutes on the floor and called her daughter who brought her to the ED. She was wearing slippers without backs at the time of the fall. She uses a cane for ambulation but was not using it in the bathroom. Patient reports one previous fall 3 months ago when she slipped on ice outside her home. Current medications include lisinopril, hydrochlorothiazide, and acetaminophen. She lives alone in a single-story home with three steps to enter. She is independent with ADLs but requires assistance with IADLs including transportation and managing finances."
Important Considerations
- Avoid using the term "mechanical fall" alone without detailed description, as it may lead to inadequate evaluation of potential underlying causes 2
- Remember that falls in elderly patients are often multifactorial, with both environmental and intrinsic factors contributing 1
- Document timing of fall, as temporal patterns exist (falls are more common during night shifts and in winter/spring months) 3
- Note that falls occurring in hospital settings most commonly happen in the patient's room (72%) or bathroom (23%) 3
- Always assess for injuries systematically from head to toe, as injuries may not be immediately apparent 1
By documenting these specific elements, you create a comprehensive HPI that facilitates proper evaluation, management, and prevention strategies for patients who have experienced falls.