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make a documentation as a psw , and mention clearly documentation date and time, signature and content.
You have been caring for John Smith, in his home, for 3 months. Mr. Smith is a diabetic, he weighs 300 lbs. and has a below the knee amputation on his left leg. When you arrive this morning, he doesn’t call for you to let yourself in as he usually does. Finding the hidden key, you let yourself in and find Mr. Smith lying on his back on the kitchen floor. He states that he stood up from his wheelchair to get a glass of water, slipped and fell on the floor. He can’t get up on his own and has been lying there for about 10 minutes. You notice that he is wearing socks, that he has a laceration on his forehead, that is bleeding, and that he can’t move his right arm. He denies feeling dizzy but complains of pain in his right arm. His BP is 160/76 and P is 88 and regular.

 
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