Improving Post‐Fall Assessment Documentation in Older Inpatients Using a Structured Falls Proforma: A Retrospective Cohort Study

ABSTRACT Objective Falls among hospital inpatients are a major cause of morbidity, mortality, and healthcare burden. The aim of this study was to evaluate the association between the use of a structured Falls Proforma and the completeness of post‐fall assessment documentation in an Australian hospital. Methods A retrospective cohort study was conducted on patients who experienced inpatient falls between January 2022 and December 2024. Fall events were stratified by 6‐month audit intervals, and cases were randomly selected within each stratum using computer‐generated sampling. All falls within this time frame were eligible for inclusion; only a patient's first fall among those aged > 65 years was counted, and data with missing details were excluded from analysis. Falls were categorized into “proforma” or “non‐proforma” groups. Documentation across 12 assessment domains was compared, and demographic and clinical characteristics associated with proforma use were evaluated. Results A stratified random sample of 202 inpatient falls was reviewed, with 167 eligible for analysis. Of these, 125 (75%) were assessed using the proforma. Documentation was significantly higher in the proforma group across examination domains: cervical spine (96.8% vs. 47.6%), hip (98.4% vs. 40.5%), cranial nerve (92.8% vs. 40.5%), upper limb neurology (93.6% vs. 45.2%), lower limb neurology (95.2% vs. 42.9%), external head (97.6% vs. 35.7%), cognition (95.2% vs. 19.0%), coagulopathy (98.4% vs. 16.7%), musculoskeletal (95.2% vs. 35.7%), mobility (92.0% vs. 7.1%), and contributing factors (87.2% vs. 59.5%) (all p < 0.001). Scenario documentation was high in both groups (85.6% vs. 95.2%, p = 0.100). In multivariable analysis, preexisting cognitive impairment was associated with lower odds of proforma use, however this association did not reach statistical significance after adjustment (OR = 0.450, 95% CI 0.190–1.030 , p = 0.062). Conclusions Use of a structured Falls Proforma was associated with significantly greater completeness of post‐fall documentation. However, lower uptake among patients with cognitive impairment may represent a disparity in documentation within a high‐risk population. Embedding structured tools into routine practice may standardize documentation and support adherence to recommended post fall assessment frameworks.