Falls Assessment (Text Version)
Resident: ____________________________________________ Room: ____________________
Directions: Use the instructions on the Falls Assessment Cue Sheet to assess the resident in the five areas listed in the first column. Put a check beside each risk factor present for this resident. If the resident does not have a risk factor, put a check beside N/A. In the second column, check when the primary care provider report is faxed and orders are received and when the resident is discussed in the interdisciplinary team meeting. Check all appropriate evaluations and referrals. Once the assessment is complete, proceed to the Fall Interventions Plan and select specific individualized interventions for each risk category identified for this resident.
Risk Factors |
Interdisciplinary Assessments
|
___ Primary Care Provider Report faxed
___ Primary Care Provider Orders received
___ Discussed in falls team meeting
|
Medications
___ Antipyschotics
___ Antidepressants
___ Benzodiazepines
___ Sedatives/hypnotics
___ Digoxin
___ N/A
| ___ Medication review by consultant pharmacist
___ Psychiatric evaluation |
Orthostatic Hypotension
___ Reduction of ≥20 mm Hg in systolic pressure 1 minute after change in position from sitting to standing
Sitting BP: ___/___ Standing BP: ___/___ ___ N/A
| ___ Review cardiovascular medications |
Vision
___ Stumbles and trips
___ Difficulty finding objects or detecting changes in floor surfaces
___ N/A
| ___ Optometrist evaluation
___ Ophthalmologist referral |
Mobility
___ Unsafe during the Get Up and Go Test
___ Unable to transfer on and off toilet, bed, or chair safely
___ Unsafe wheelchair seating
___ N/A
| ___ OT consultation
___ PT consultation |
Unsafe Behaviors
___ Tries to stand, transfer, or walk alone unsafely
___ Tries to climb over bed rails or get out of bed alone unsafely
___ Walks or paces alone in unsafe areas
___ N/A
| ___ Behavioral assessment
___ Evaluation of restraint use |
Signature: _______________________________ Date Completed: ________________________
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