FALL RISK ASSESSMENT – West Region
Individual:
Baseline Date: / / Assessed By: , RN Date: / /
|Section 1: |Section 2: |
| | |
|Is individual ambulatory? |Plan: |
|YES NO | |
| |Proper footwear |
|Potential risk factors present? |Environmental changes |
|1. Diagnosed dementia |Well lit room |
|2. Gait abnormality |Encourage to change positions slowly |
|3. Seizure disorder |Assistive device, i.e., cane, walker |
|4. Behavior (e.g., rushing) |Assist with positioning |
|5. Sensory impairment |Assist with ambulation in unfamiliar areas |
|6. Medication effects |Assist with ambulation on stairs |
|(e.g., behavior–modifying or blood pressure medication, anticonvulsants) |Assist with ambulation on uneven surfaces |
|7. Orthostatic hypotension |Assist with all ambulation |
|B/P Lying / |Monitor follow-up PRN |
|B/P Standing / |Other: |
|8. Other (e.g., environmental factors, medical diagnoses with risk potential) | |
|Specify: | |
| |Referral: |
|Significant Injury Risk: | |
|Osteoporosis/Osteopenia |PT |
|Anticoagulant use |OT |
|Fracture History |Psych/Behavioral |
|Other |MD |
|Specify: |Other |
|Recorded fall in last three months? | |
|NO | |
|YES High Risk | |
| | |
|Plan in place to address above risks? | |
|YES Assessment is complete | |
|NO Complete Section #2 | |
Fall Risk Assessment Algorithm for Consultation
|Impaired Mobility | |Demo unsafe behavior or choices | |ADL deficits | |Elimination deficit |
|History of falls | | | |Sensory deficits | |Medication issues |
|Weakness | | | |Decreased cognition | |Predisposing DX |
|Non-compliance with activity restrictions | | | |Living environment concerns | |Uncontrolled pain |
| | | | |Physical limitations | |Medical decline |
|P.T. | |Psych/Behavioral | |O.T. | |Medical |
Individual: Review Date(s): / / Plan remains appropriate? YES*NO** *Team Signatures Only** Plan Revision Indicated Revision: Identify factors that can be staff intervention and Identify any further evaluation needed Plan Revision/Review Date: / /
| |
|Signatures: |
| | | |
| | | |
| | | |
Plan Revision/Review Date: / / Plan remains appropriate? YES*NO**
| |
| Signatures: |
| | | |
| | | |
| | | |
Plan Revision/Review Date: / / Plan remains appropriate? YES NO**
| |
| Signatures: |
| | | |
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