Fall Risk Assessment Form PDF Details

In the realm of healthcare and senior living facilities, the Fall Risk Assessment Form is a critically important tool designed to identify individuals at higher risk of falling. This form evaluates a multitude of factors including a resident’s fall history, ambulatory and continence status, mental orientation, vision quality, gait and balance, blood pressure stability, medication intake, and any predisposing conditions such as cardiovascular or musculoskeletal disorders. By addressing categories like the recent fall history which quantifies falls within a specific timeframe, to more nuanced assessments of an individual’s gait, balance, and medication effects, the form offers a comprehensive overview of risk elements. Additionally, it incorporates a scoring system whereby the accumulation of points can signify the resident’s level of risk, with a total score of 10 or more pointing towards a heightened fall risk. This meticulous approach signals the necessity for tailored preventive measures or interventions to safeguard the well-being of those deemed at risk. Originating from efforts by IPRO under the auspices of the Centers for Medicare & Medicaid Services, this form represents a vital step in proactive health management and falls prevention strategy within care settings.

QuestionAnswer
Form NameFall Risk Assessment Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesrisk fall form, fall form risk, fall risk assessment form pdf, form risk fall

Form Preview Example

FALL RISK ASSESSMENT FORM

Resident Name-

 

 

Rm-

 

 

 

 

 

Check off reason for assessment

 

 

 

 

 

Initial Assessment

 

Re-Assessment after fall

 

 

 

 

 

Re-Assessment (periodic)

 

Change in Status

 

 

 

 

 

 

Circle reference

 

Total reference

Categories

number(s) in

Descriptions

numbers by

 

each category

 

category

 

 

 

 

 

0

NO FALLS in past 3 months

 

Recent Fall History

 

 

 

2

1 - 2 FALLS in past 3 months

 

 

4

3 OR MORE FALLS in past 3 months

 

 

 

 

 

 

0

AMBULATORY/CONTINENT

 

Ambulation / Continence

 

 

 

2

CHAIR BOUND - Requires assist with elimination

 

 

4

AMBULATORY/INCONTINENT

 

 

 

 

 

 

0

ALERT (oriented X 3) OR COMATOSE (no voluntary or

 

 

involuntary movement)

 

 

 

 

Mental Status

2

DISORIENTED X 3 at all times

 

 

 

 

 

 

4

INTERMITTENT CONFUSION / forgets limitations

 

 

 

 

 

 

0

ADEQUATE (with or without glasses)

 

Vision

 

 

 

2

POOR (with or without glasses)

 

 

4

LEGALLY BLIND

 

 

 

 

 

 

To assess, have resident 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

 

 

 

 

 

Balance

1

Balance problem while walking

 

 

 

 

1

Decreased muscular coordination

 

 

 

 

 

 

 

 

1

Change in gait pattern when walking through doorway

 

 

 

 

 

 

1

Unstable when making turns

 

 

 

 

 

 

1

Requires use of assistive devices (i.e., cane, w/c, walker,

 

 

furniture)

 

 

 

 

 

1

Inappropriate use of assistive device / footwear

 

 

 

 

 

 

0

NO NOTED DROP between lying and standing

 

 

 

 

 

Blood Pressure (Systolic)

2

Drop LESS THAN 20 mm Hg between lying and standing in

 

3 minutes

 

 

 

 

4

Drop MORE THAN 20 mm Hg between lying and standing

 

 

in 3 minutes

 

 

 

 

 

Diuretics (somnolence, volume depletion, electrolyte disturbance, urgency to rush to

 

bathroom), Psychoactives: Benzodiazepines (i.e. Ativan, Halcion), Phenothiazines,

 

Antidepressants, and antipsychotics (i.e., Mellaril and Haldol), Narcotics, Anticonvulsant

 

stabilizers, Cardiovascular medications, Corticosteroids (can adversely effect muscle

 

function), or any medication that adversely affects muscle function, coordination, and physical

 

stability.

 

 

 

0

NONE of these medications taken currently or within last 7

 

Medications

days

 

 

 

 

2

TAKES 1 - 2 of these medications currently and/or within

 

 

last 7 days

 

 

 

 

 

4

TAKES 3 - 4 of these medications currently and/or within

 

 

last 7 days

 

 

 

 

 

 

If resident has had a change in medications and/or

 

 

1

change in dosage in the past 5 days = score 1 additional

 

 

 

point

 

 

Gastrointestinal: Bleeding, Diarrhea, Defecation Syncope, Postprandial Syncope,

 

Genitourinary: Micturition syncope, Incontinence, Nocturia (80% of the elderly experience

 

nocturia and going to the bathroom at night is a major risk factor), Cardiovascular: Myocardial

 

infarction, Arrhythmia, Orthostatic Hypotension, Musculoskeletal disorders: Arthritis,

Predisposing Conditions

Inflammatory Joint Disease, Osteoarthritis Proximal Myopathy, Deconditioning, Neurologic:

Parkinsonian, Dementia, Stroke, Transient Ischemic Attack, Delirium, Myelopathy,

or

Vertebrobasilar Insufficiency, Carotic Sinus Supersensitivity, Cerebellar Disorder, Peripheral

Diseases

Neuropathy, Diabetes, B12 Deficiency, Multiple Myeloma, Vasculitis, Chronic dehydration

 

 

 

 

 

 

 

 

0

NONE PRESENT

 

 

 

 

 

 

2

1 - 2 PRESENT

 

 

 

 

 

 

4

3 OR MORE PRESENT

 

 

 

 

 

A TOTAL SCORE OF 10 OR MORE INDICATES A

TOTAL SCORE--->

 

RESIDENT "AT RISK" FOR FALLS.

 

 

 

This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-NY-AIM7.2-11-24

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1. While filling out the fall risk assessments, make sure to complete all important blanks within the corresponding part. This will help facilitate the work, allowing your details to be handled quickly and correctly.

Stage no. 1 of completing fall risk form

2. Once your current task is complete, take the next step – fill out all of these fields - Balance, Blood Pressure Systolic, Medications, Predisposing Conditions, Diseases, Balance problem while standing, Balance problem while walking, Decreased muscular coordination, Change in gait pattern when, Unstable when making turns, Requires use of assistive devices, Inappropriate use of assistive, NO NOTED DROP between lying and, Drop LESS THAN mm Hg between, and Diuretics somnolence volume with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Part number 2 in submitting fall risk form

Always be very mindful when completing Predisposing Conditions and Balance, as this is where a lot of people make errors.

3. The next step will be straightforward - fill out every one of the empty fields in NONE PRESENT, PRESENT, OR MORE PRESENT, A TOTAL SCORE OF OR MORE, RESIDENT AT RISK FOR FALLS, TOTAL SCORE, and This material was prepared by IPRO to complete this segment.

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