Why falls records matter

Falls are among the most important indicators of increased care needs. They are objective events with real safety consequences, and CLSC assessors take them seriously.

A verbal statement — "she's fallen a few times recently" — is less persuasive than a written record with specific dates and circumstances. Documentation moves falls from a vague impression to a concrete, specific safety concern.

Even if a fall resulted in no injury, it should be recorded. Near-falls (where the person grabbed something to catch themselves, or had to be physically caught) are also worth noting.

What to record for each fall

For each fall or near-fall, write down:

• Date — as specific as possible; at minimum, the week
• Time of day — morning, afternoon, evening, or night
• Location — bathroom, bedroom, kitchen, outdoors, stairs, etc.
• What happened — what the person was doing when they fell
• Apparent cause — loss of balance, dizziness, tripping on something, legs gave out, etc.
• Injuries — none, bruising, cut, fracture, head injury, etc.
• Was emergency services called? — and if so, what happened
• Was the person alone? — or was a caregiver present

How to keep the record

A simple notepad, a notebook, or a note on your phone works well. The format does not matter — the content does.

If you are already keeping a caregiver journal, falls can be recorded there alongside other observations.

What to do after a fall

• Consult a physician if there is any possibility of injury, especially if the fall involved the head or if the person complains of pain
• Notify the care coordinator at the CLSC
• Add the event to your written record while details are fresh

What a falls record shows an assessor

When you arrive at a CLSC assessment with a written record of four falls in six months — with dates, locations, and circumstances — it communicates clearly that this is a pattern, not a one-time event. It changes the assessor's picture from "occasional falls" to a documented and ongoing safety risk.

One well-documented fall can justify a referral to physiotherapy or OT. Multiple documented falls often support a case for increased personal care or supervision.

What should I gather next?

See the Medical Documentation Checklist for other records to prepare before a CLSC assessment or reassessment.