Falls Risk Assessment

ADVERTISEMENT

FALLS RISK ASSESSMENT
State Form 53502 (R / 11-09)
FAMILY & SOCIAL SERVICES ADMINISTRATION
MADISON STATE HOSPITAL
Admission
Annual
Post-Fall
Other _________________
Circle appropriate score for each section and total score at bottom.
Parameter
Score
Patient Status/Condition
0
Alert and oriented X 3
Level of Consciousness/
A.
2
Disoriented X 3
Mental Status
4
Intermittent confusion
0
No falls
History of Falls
B.
2
1-2 falls
(past 3 months)
4
3 or more falls
0
Ambulatory & continent
Ambulation/
C.
2
Chair bound & requires assistance with toileting
Elimination Status
4
Ambulatory & incontinent
0
Adequate (with or without glasses)
D.
Vision Status
2
Poor (with or without glasses)
4
Legally blind
Have patient stand on both feet w/o any type of assist then have walk: forward, thru a
doorway, then make a turn.
(Mark all that apply.)
0
Normal/safe gait and balance.
1
Balance problem while standing,
1
Balance problem while walking.
E.
Gait and Balance
1
Decreased muscular coordination.
1
Change in gait pattern when walking through doorway.
1
Jerking or unstable when making turns.
1
Requires assistance (person, furniture/walls or device).
No noted drop in blood pressure between lying and standing.
0
No change to cardiac rhythm.
Orthostatic
Drop<20mmHg in BP between lying and standing.
F.
2
Changes
Increase of cardiac rhythm <20.
Drop >20mmHg in BP between lying and standing.
4
Increase of cardiac rhythm>20.
Based upon the following types of medications: anesthetics, antihistamines, cathartics,
diuretics, antihypertensive, antiseizure, benzodiazepines, hypoglycemic, psychotropic,
sedative/hypnotics.
0
None of these medications taken currently or w/in past 7 days.
G.
Medications
2
Takes 1-2 of these medications currently or w/in past 7 days.
4
Takes 3-4 of these medications currently or w/in past 7 days.
Mark additional point if patient has had a change in these medications or
1
doses in past 5 days.
Based upon the following conditions: hypertension, vertigo, CVA, Parkinsons Disease,
loss of limb(s), seizures, arthritis, osteoporosis, fractures.
Predisposing
0
None present
H.
Diseases
2
1-2 present
4
3 or more present
0
No risk factors noted
1
Oxygen tubing
I.
Equipment Issues
1
Inappropriate or client does not consistently use assistive device.
1
Equipment needs:
1
Other:
Score of 8 to 14
= Moderate risk for falls
TOTAL SCORE
Score of 15 or Above = High risk for falls
If score is 8 or above, the back page of this form must be completed.
Patient has been informed about fall risk assessment results and/or safety/fall prevention recommendations:
Yes
No
Signature of RN
Date (Month, day, year)
Time
Addressograph

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 2