February 14, 2025
It’s snow season here in New York! While winter may bring exciting opportunities for fun, individuals with disabilities are often at an elevated risk of falling during these icy winter months. Slippery terrain, improper footwear, new or unfamiliar surroundings, and distractions can all cause a person to accidentally stumble and fall.
What should you do if you witness or suspect that a person receiving services may have fallen? Conduct a body check.
Body checks are a simple yet vital tool for assessing someone for injuries after a fall. They help us ensure a person’s well-being and get them the care they need when they need it. The key to effective body checks is in both the timing and how they are conducted.
Make safety a priority by following these best practices.
Complete Body Checks: Follow the guidance outlined in plans of care to conduct and document body checks on people receiving services. Note any marks or injuries found. If marks or injuries are noted, repeat and document body checks until all marks or injuries are healed. Seek medical attention from nurses, primary care physicians, or urgent care for any marks or injuries that require medical care.
Document Everything: Be sure to write clearly so that fellow staff, nurses, and managers can read the body check form. This will save time later. Don’t forget to sign and date the body check form. Include a printed name and staff title next to all signatures.
Be Descriptive: Include details when documenting marks or injuries found during body checks. Note whether it was completed for the person’s whole body or just one area, whether marks or injuries were old or new, and their size, color, and location.
For example, a quarter-sized faded bruise, light purple in color, was located on the individual’s shin bone, just below his right knee.
Add a Photo? Consult your agency’s policies for requirements or restrictions on photographing marks or injuries found during body checks. This includes photographs to document an injury or the absence of one if it is being completed after an incident or the progression of an injury following its initial identification. Check with a supervisor or manager before taking a picture to confirm it is okay.
Avoid using a personal cell phone to take or text photographs of people receiving services. Remember your HIPAA training!
Practice Sensitivity: Consider what the individual needs to feel comfortable and safe when preparing to conduct a body check. Explain what will happen before beginning the body check and while completing it. Demonstrate understanding and patience if an individual refuses to consent. Document the refusal and seek support from a manager or a supervisor.
Fill in the Blanks: Complete all areas of the body check form, and don’t leave any blanks. Include the type of mark or injury, the location, possible cause, whether the person required medical treatment, and whether the nursing department was notified.