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    Fall Risk Assessment Form

    Uploaded by

    Michael Silva
    This document contains a fall risk assessment form for a nursing home resident. It assesses 8 risk parameters, including mental status, history of falls, ambulation/elimination status, vision, gait/balance, blood pressure, medications, and predisposing medical conditions. Each parameter is given a score and the scores are totaled at the end. A total of 10 points or more indicates a high risk of falls. For high-risk residents, fall prevention interventions are identified and their effectiveness evaluated.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Fall Risk Assessment Form

    Uploaded by

    Michael Silva
    1K views3 pages
    This document contains a fall risk assessment form for a nursing home resident. It assesses 8 risk parameters, including mental status, history of falls, ambulation/elimination status, vision, gait/balance, blood pressure, medications, and predisposing medical conditions. Each parameter is given a score and the scores are totaled at the end. A total of 10 points or more indicates a high risk of falls. For high-risk residents, fall prevention interventions are identified and their effectiveness evaluated.

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    This document contains a fall risk assessment form for a nursing home resident. It assesses 8 risk parameters, including mental status, history of falls, ambulation/elimination status, vision, gait/balance, blood pressure, medications, and predisposing medical conditions. Each parameter is given a score and the scores are totaled at the end. A total of 10 points or more indicates a high risk of falls. For high-risk residents, fall prevention interventions are identified and their effectiveness evaluated.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    1K views3 pages

    Fall Risk Assessment Form

    Uploaded by

    Michael Silva
    This document contains a fall risk assessment form for a nursing home resident. It assesses 8 risk parameters, including mental status, history of falls, ambulation/elimination status, vision, gait/balance, blood pressure, medications, and predisposing medical conditions. Each parameter is given a score and the scores are totaled at the end. A total of 10 points or more indicates a high risk of falls. For high-risk residents, fall prevention interventions are identified and their effectiveness evaluated.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    You are on page 1of 3

    _____________________________________________________________

    (Name of Facility)

    Fall Risk Assessment Form


    Resident's Name:

    Physician:
    Examiner
    Assessment Date

    PARAMETER

    SCORE

    Level of
    A. Consciousness/
    Mental Status

    B.

    History of Falls
    (past 3 months)

    C.

    Ambulation/
    Elimination
    Status

    D.

    Vision Status

    E.

    Gait/Balance

    F.

    Systolic Blood
    Pressure

    G.

    Medications

    H.

    Predisposing
    Diseases

    RESIDENT STATUS/CONDITION

    Enter Evaluation Score


    Below

    ALERT (oriented X 3) OR COMATOSE

    2
    DISORIENTED X 3 at all times
    4
    INTERMITTENT CONFUSION
    0
    NO FALLS in past 3 months
    2
    1 - 2 FALLS in past 3 months
    4
    3 OR MORE FALLS in past 3 months
    0
    AMBULATORY/CONTINENT
    2
    CHAIR BOUND - Requires restraints and assist with elimination
    4
    AMBULATORY/INCONTINENT
    0
    ADEQUATE (with or without glasses)
    2
    POOR (with or without glasses)
    4
    LEGALLY BLIND
    To assess the resident's Gait/Balance, have him/her stand on both feet
    without holding onto anything; walk straight forward; walk through a
    doorway; and make a turn.
    0
    Gait/Balance normal
    1
    Balance problem while standing
    1
    Balance problem while walking
    1
    Decreased muscular coordination
    1
    Change in gait pattern when walking through doorway
    1
    Jerking or unstable when making turns
    Requires use of assistive devices (i.e., cane, w/c, walker,
    1
    furniture)
    0
    NO NOTED DROP between lying and standing
    2
    Drop LESS THAN 20 mm Hg between lying and standing
    4
    Drop MORE THAN 20 mm Hg between lying and standing
    Respond below based on the following types of medications: Anesthetics,
    Antihistamines, Antihypertensives, Antiseizure, Benzodiazepines,
    Cathartics, Diuretics, Hypoglycemics, Narcotics, Psychotropics,
    Sedatives/Hypnotics.
    NONE of these medications taken currently or within last 7
    0
    days
    TAKES 1 - 2 of these medications currently and/or within last
    2
    7 days
    TAKES 3 - 4 of these medications currently and/or within last
    4
    7 days
    If resident has had a change in medications and/or change
    1
    in dosage in the past 5 days = score 1 additional point
    Respond below based on the following predisposing conditions:
    Hypotension, Vertigo, CVA, Parkinson's disease, Loss of limb(s), Seizures,
    Arthritis, Osteoporosis, Fractures.
    0

    NONE PRESENT

    1 - 2 PRESENT

    3 OR MORE PRESENT

    Total score of 10 or above


    represents HIGH RISK

    Fall Prevention & Management Program

    TOTAL SCORE:

    Page 1 of 3

    Falls Form 1 - FRA

    _____________________________________________________________
    (Name of Facility)

    Fall Risk Assessment Form


    If resident scored a 10 or above, interventions should be initiated. Document interventions below and on the resident's care plan.
    Resident should be informed of the risk/benefits associated with each intervention.
    Intervention

    By:

    Date Intervention Reviewed:

    By:

    Date Initiated:

    Intervention effective? Yes


    No
    Follow-up required? Yes
    No

    Comments:
    Intervention

    By:

    Date Intervention Reviewed:

    By:

    Date Initiated:

    Intervention effective? Yes


    No
    Follow-up required? Yes
    No

    Comments:
    Intervention

    By:

    Date Intervention Reviewed:

    By:

    Date Initiated:

    Intervention effective? Yes


    No
    Follow-up required? Yes
    No

    Comments:
    Date

    Fall Prevention & Management Program

    Notes

    Page 2 of 3

    Initials

    Falls Form 1 - FRA

    _____________________________________________________________
    (Name of Facility)

    ID #

    Room #

    Fall Prevention & Management Program

    Resident Name:

    Physician:

    Page 3 of 3

    Falls Form 1 - FRA

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