Older-adult fall & hip injury: documentation that holds up
A ground-level fall in an older adult is rarely "just a fall." The defensible chart documents the search for an occult hip fracture a plain film can miss, asks why the patient fell, checks the head in the anticoagulated, recognizes the harms of a long lie, and tests whether the patient can safely walk before discharge.
01What's at stake
Up to a tenth of hip fractures are occult on initial radiographs — and an older adult who can't bear weight after a fall has a hip fracture until advanced imaging says otherwise. The fall itself may be the presenting sign of syncope, sepsis, arrhythmia, stroke, or a medication problem. The anticoagulated head that struck the floor can bleed slowly. And a patient who lay on the floor for hours risks rhabdomyolysis, AKI, pressure injury, and hypothermia.
02Can't-miss issues
- Occult hip fracture — pain and inability to bear weight with a normal x-ray → MRI (or CT) before discharge. → advanced imaging
- The cause of the fall — syncope, arrhythmia, sepsis, stroke, hypoglycemia, medication/orthostasis; the fall is a symptom. → fall workup
- Anticoagulated head injury — delayed intracranial bleeding; image and observe. → CT head
- Long lie — rhabdomyolysis/AKI, pressure injury, dehydration, hypothermia.
- Other fractures (pelvis, wrist, proximal humerus, vertebral) and the elder-abuse consideration.
03Assessment
- Hip imaging — plain films first; if negative but the patient can't bear weight or has persistent pain, get MRI/CT. → hip imaging
- Ambulation test — document a safe, independent walk (or its failure) before discharge. → ambulation
- Fall-cause screen — ECG, glucose, vitals/orthostatics, infection screen, neuro exam, medication review. → fall screen
- Head CT for the anticoagulated or those with head strike/AMS; CK/renal function after a long lie.
Skip the typing
Work the case in the Hip Injury / Fall Workup — it records the hip imaging (including advanced imaging for occult fracture), the fall-cause screen, and the ambulation test, and assembles an MDM that documents the occult fracture and the cause of the fall were addressed.
04Management
- Hip fracture: analgesia (consider a fascia-iliaca/regional block), orthopedics, and early operative planning; VTE prophylaxis.
- Occult fracture: don't discharge the non-ambulatory patient on a normal x-ray — image further.
- Treat the cause of the fall and the consequences of a long lie (fluids for rhabdomyolysis/AKI, rewarming, wound care).
- Disposition: fall-risk assessment, physical therapy/gait evaluation, home-safety and medication review; admit those who can't safely ambulate or have a serious cause.
05What to document
06Where charts fail
- Discharging a non-ambulatory older patient on a normal hip x-ray (missed occult fracture).
- Treating the injury and never asking why the patient fell.
- Missing delayed intracranial bleeding in the anticoagulated head strike.
- Missing rhabdomyolysis/AKI after a long lie.
- No documented ambulation test or fall-risk/medication review before discharge.
07Sources
- Parker M, Johansen A. Hip fracture. BMJ. 2006;333(7557):27-30.
- Cannon J, Silvestri S, Munro M. Imaging choices in occult hip fracture. J Emerg Med. 2009;37(2):144-152.
- Carpenter CR, Avidan MS, Wildes T, et al. Predicting geriatric falls following an episode of emergency department care: a systematic review. Acad Emerg Med. 2014;21(10):1069-1082.
- American Geriatrics Society/British Geriatrics Society. Clinical practice guideline: prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):148-157.
© 2026 Kim Trinh, MD. All rights reserved. Educational only — synthesized from primary literature and guidelines. Synthetic examples. Not medical advice — apply local protocol and judgment.