Staff member states that patient was walking across the room when she tripped and fell and landed on her head in the prone position. Staff member states that patient picked herself up off the floor and was not crying or showing any signs of distress.
Upon examination of the patient, Patient is alert and oriented and acting appropriate for her age. Patient is showing no obvious signs of distress. Patient has an approximately half inch by half inch red spot to her right eyebrow proximal to the patient’s nose. Patient denies pain to the affected area. No swelling noted.
Patient left in the care of staff members and parents were notified of the incident.
Staff states that patient fell down on the floor, but did not witness the patient strike her head or any other body part. Staff members are concerned because the patient vomited one time.
Upon assessment, patient is a three-year-old female showing no obvious signs of distress and acting appropriate for her age. When asked if she fell down, patient said “yes”When asked if she hit her head or face patient said “no”. When I asked if she threw up, patient said.”yes”. When asked if she still felt sick, patient said “no”.
Patient left in the care of staff members and parents were notified of the incident. No other care was needed or rendered.
