7.3 Patient Safety, Emergency Response & Documentation

Falls Prevention During Treatment

Falls are the most common preventable adverse event in physical therapy. The PTA controls fall risk before and during every session:

• Use a gait belt for all ambulation and transfer training — apply it snugly over clothing at the waist, never around bare skin or over a recent surgical site.
• Scan the environment for tripping hazards: clutter, cords, throw rugs, wet floors, and poor lighting.
• Check footwear — non-skid, closed-back, properly fitted shoes; treat barefoot or socks-only ambulation as a hazard.
• Lock wheelchair and bed brakes before every transfer and confirm equipment is within reach.
• Guard on the patient's weaker or more affected side and stay slightly behind.

---

Emergency Response

Syncope and Cardiac Arrest

If a patient faints or collapses:

1. Call for help — activate the facility code or 911.
2. Position the patient supine; elevating the legs can aid venous return if syncope is suspected.
3. Check responsiveness and pulse. If the patient is pulseless, begin CPR immediately.
4. Apply an AED as soon as one is available and follow its prompts.

High-quality cardiopulmonary resuscitation (CPR) means compressions at 100 to 120 per minute, a depth of about 2 inches in adults, and full chest recoil. An automated external defibrillator (AED) analyzes the rhythm and delivers a shock only if indicated.

Choking

For a conscious adult with a complete airway obstruction (cannot speak, cough, or breathe), deliver abdominal thrusts until the object is expelled or the patient becomes unresponsive — then begin CPR and call for help.

Seizure Response

• Do NOT restrain the patient and do NOT put anything in the mouth.
• Lower the patient to the floor, protect the head, and clear nearby hazards.
• Time the seizure — an event lasting longer than 5 minutes, or repeated seizures, is a medical emergency (status epilepticus).
• When the seizure ends, place the patient in a recovery (side-lying) position to protect the airway, and monitor until fully alert.

---

Incident Reporting

Any fall, equipment failure, or adverse event requires a factual incident report completed promptly. Document objectively what happened, not opinions or blame. The incident report is an internal risk-management record and is generally not filed in the patient's medical chart.

---

SOAP Documentation

PTAs document each treatment session using the SOAP format:

Every PTA note must be signed by the PTA with credentials. Under Medicare, a PTA's daily treatment notes do not require routine PT countersignature, but the PT must write and sign a progress note at least every 10 treatment days or every 30 calendar days, whichever comes first, to document re-assessment and continued medical necessity.