After an older adult falls, the family may notice changes in walking, bathing, cooking, driving, medication routines, supervision, or living arrangements. A useful record begins with the person’s actual pre-fall function. Age alone does not establish dependence, and a later need for help should not be attributed to the fall without a dated source and appropriate medical review.

An older-adult function record should compare the documented pre-fall baseline with specific post-fall changes in mobility, self-care, household activity, transportation, supervision, equipment, living setting, and assistance.

Build a source-based pre-fall baseline

The National Institute on Aging explains that understanding an older patient’s usual functioning and recent changes is fundamental to health care and discusses basic activities of daily living in its guidance on obtaining an older patient’s medical history. A legal record should preserve the source of the baseline instead of assuming that the person needed help before the fall.

  • Residence and living arrangement, stairs and access, ordinary schedule, work or volunteer role, caregiving, errands, and community activity
  • Walking distance, standing, transfers, stairs, bathing, dressing, toileting, eating, cooking, cleaning, shopping, medication routine, driving, and transit
  • Device, home feature, vehicle adaptation, home-health service, family help, paid assistance, supervision, or transportation used before the fall
  • Medical record, therapy assessment, care plan, calendar, work record, service invoice, family or friend observation, photograph, video, device record, or other source

Create dated post-fall change entries

  • Task attempted, date, place, duration, assistance, device, rest, safety concern, observable result, and source
  • Clinical restriction or instruction reproduced exactly with provider, date, record, review date, and later revision
  • Family, friend, aide, nurse, therapist, facility, transportation service, or vendor providing help and the task performed
  • Temporary residence, rehabilitation, assisted living, home-health, equipment, home change, transportation, or supervision and the document authorizing or recording it

Keep fall-risk information separate from legal responsibility

The National Institute on Aging identifies many possible contributors in its guidance on falls and fractures in older adults, including health, medication, vision, strength, balance, and environmental considerations. Those general factors do not determine why a particular fall occurred. Preserve the person’s medical and functional evidence, property condition, warning and notice evidence, footwear and device information, witness accounts, and alternative explanations without assigning fault from age or diagnosis.

Request the underlying medical and billing sources

HHS explains that, with exceptions, individuals may inspect, review, and receive copies of medical and billing records held by covered providers and health plans. Request the relevant emergency, hospital, imaging, surgery, therapy, rehabilitation, home-health, equipment, restriction, discharge, and billing records rather than relying on a family summary or appointment list.

  • Pre-fall diagnoses, restrictions, devices, function assessments, prior falls, treatment, living support, and transportation kept as a dated baseline
  • Post-fall diagnosis, examination, image, procedure, restriction, therapy measurement, equipment, referral, and discharge plan recorded as the provider stated it
  • Prior condition, later event, medication change, unrelated illness, conflicting record, correction, and missing source preserved for qualified review
  • Bills, payments, adjustments, benefit records, service invoices, caregiver time records, and current balances tied to the correct person and date

Separate lay observation from professional opinion

North Carolina Rule of Evidence 702 addresses qualified expert testimony. Family members can document what they personally observed and what assistance they supplied. Diagnosis, medical causation, fall mechanism, prognosis, permanence, future care, life-care planning, and whether a property condition caused the injury require an appropriate foundation.

Track assistance without overstating it

  • Task, provider, relationship, date, start and end time, frequency, paid or unpaid status, source, and changes over time
  • Assistance actually provided kept separate from an estimated future need or recommendation
  • Shared household work allocated to the person who performed it, without duplicating a medical, wage, or service expense
  • Improvement, setback, stopped service, changed living setting, resumed task, and the source supporting the change

The related guide to documenting household assistance and daily function after a serious injury provides the general task ledger. This page owns the older-adult pre-fall baseline and the transition among independence, assistance, supervision, equipment, and living settings.

Rosensteel Fleishman Car Accident & Injury Lawyers provides information about Charlotte slip-and-fall claims involving older adults. A baseline-and-assistance record documents change; it does not establish property responsibility, medical causation, future needs, damages, or the result.

Sources