Fillable Printable Fall Risk Assessment Template
Fillable Printable Fall Risk Assessment Template
Fall Risk Assessment Template
Fall Risk Assessment
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Use this form as a guide to assess the resident’s fall risk factors in the categories listed below through physical examination, observation and
interaction with resident. For each category, place a check next to characteristic that best describes resident. The shaded characteristics indicate
increasing levels of risk. The greater the number of checks belonging to that category, the greater risk of falls. Under evaluation describe how this
category aects the resident. Fall management applies for all residents, especially for those who:
•Wererecentlyadmittedorhaveachangeinrooms•Haveachangeinphysical/emotionalstatus
•Wererecentlyhospitalized •Haveexperiencedarecentfall
* Any identied risk factor should be addressed on the care plan.
Refer to “Restraints & Falls: Alternative Interventions” tool.
Resident Name:
Room #:
Physician:
Diagnoses:
Key:
CaTegoRy ChaRaCTeRisTiC 1 2 3 4 evalUaTioN
Mental
StatuS:
Mobility:
level of
Consciousness
ambulatory aid
gait
alert, oriented, or comatose
Knows own limits, reliable safety awareness
Diminished safety awareness
Poor recall and judgment
Bed rest/wheelchair/no assistance needed
Crutches/cane/walker needed
Furniture used for support
Balance problem while standing
Normal walking/striding without hesitation
Weak walking and short, shued steps,
lightly touching furniture for support
Balance problem while walking, stoop
shoulders, able to lift head
instability while turning
impaired walking with diculty rising from
chair, head down, grasps furniture
Blood Pressure
No noted drop between lying and standing
Drop less than 20 mm hg between lying
and standing
Drop MoRe than 20 mm hg between lying
and standing
Balance
external
applications
No external devices used (iv, heparin lock,
feeding tube, cast/brace, foley catheter)
Casts/braces are present
Resident uses a foley catheter
ambulatory without assistance
able to stand/walk, maintain body alignment
Wheelchair ambulation assistance needed
iv or heparin lock is present
high Risk
low Risk Moderate Risk
Balance problem while walking, stoop
shoulders, unable to lift head
Feeding tube is present
assessment Date
#1
assessment Date
#2
assessment Date
#3
assessment Date
#4
MO-09-09-NH March 2009 This material was prepared by Primaris, the Medicare Quality improvement organization for Missouri, under contract with the Centers for Medicare &
Medicaid services (CMs), an agency of the U.s. Department of health and human services, and adapted from lhCR. The contents presented do not necessarily reect CMs policy.
Fall Risk Assessment
Document available at www.primaris.org
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CaTegoRy ChaRaCTeRisTiC 1 2 3 4 evalUaTioN
Medical StatuS/
HiStory:
Fall history
Medications
Predisposing
Diseases/
Conditions
Respond below based on these medications:
anesthetics, antihistamines, antihypertensives,
antiseizures, benzodiazepines, cathartics, diuretics,
hypoglycemics, narcotics, psychotropics, sedatives/
hypnotics
Currently takes none of these medications
No falls in past 3 months
1-2 falls in past 3 months
3 or more falls in past 3 months
Currently takes 1-2 of these medications
Currently takes 3-4 of these medications
a change in medication and/or dosage in
past 5 days
Respond below based on these conditions:
hypotension, vertigo, CVA, Parkinson’s, loss of
limb(s), seizures, arthritis, osteoporosis, fractures,
dementia, delirium, anemia, wandering, anger
None present
1-2 present
3 or more present
vision/hearing
legally Blind or very hard of hearing/deaf
Poor (with or without glasses/hearing aid)
adequate (with or without glasses/hearing
aid)
Resident Name:
Room #:
Physician:
Diagnoses:
assessor Name:
Date:
1.
assessor Name:
Date:
3.
assessor Name:
Date:
2.
assessor Name:
Date:
4.
Continence
status
ambulatory/continent
Wheelchair or ambulatory aid/continent
ambulatory/incontinent
Wheelchair or ambulatory aid/incontinent
Key:
high Risk
low Risk Moderate Risk
assessment Date
#1
assessment Date
#2
assessment Date
#3
assessment Date
#4
