Ivy Tech CNA Exam Practice 2026 – Complete Study Resource

When a resident falls, the most important thing is to capture a clear, factual record of what happened. Document the exact time and location of the fall, who was present, and any injuries you or others observed. Note the actions you took in response—such as calling for help, assisting the resident, evaluating for injuries, and notifying the nurse or supervisor—and any treatments or precautions you applied (for example, applying a cold pack if policy allows, or transferring the resident to a safe position). This combination of time, place, people involved, injuries observed, and actions taken provides a complete picture for ongoing assessment, care planning, and safety reviews. It also helps protect the resident by ensuring accurate information is available for medical evaluation and future prevention. Personal opinions about the resident’s mood or thoughts aren’t appropriate in the medical record, and documenting only the time without the rest of the details would leave important information out.