Falls Risk Assessment Falls Risk Assessment Form Select Patient-- Select Patient --Patient Full NameCheck the appropriate box for patients. Admission Resumption Post Fall Other Check the appropriate scores for each section and total the score at the bottom Parameter A. Level of Consciousness/Mental Statu Score 0 2 4 Patient Status/Condition Alert and Oriented Disoriented Intermittent Confusion Parameter B. History of falls in the last three months Score 0 2 4 Patient Status/Condition Alert and Oriented Disoriented Intermittent Confusion Parameter C. Ambulation/Elimination status Score 0 2 4 Patient Status/Condition Alert and Oriented Disoriented Intermittent Confusion Parameter D. Ambulation/Elimination status Score 0 2 4 Patient Status/Condition Alert and Oriented Disoriented Intermittent Confusion Parameter E. Have patient stand on both feet w/o any type of assist, then have walk:forwards toward doorway, then make a turn (mark all that apply) Score 0 1 1 1 1 1 1 1 Patient Status/Condition normal/safe gait and balance Balance problem while standing Balance problem while walking Decreased muscle coordination Change in gait pattern when walking through doorway Jerking or unstable when making turn Requires assistance (person, furniture/walls or device) Have patient stand on both feet w/o any type of assist, then have walk:forwards toward doorway, then make a turn (mark all that apply) Parameter F. Orthostatic Changes Score 0 2 4 Patient Status/Condition No noted drop in B/P between lying and standing, no change in heart rhythm n B/P<20 mm/hg between lying and standing, increase in heart rate < Drop in B/P<20 mm/hg between lying and standing, increase in heart rate Parameter G. Medications Score 0 2 4 1 Patient Status/Condition None of these medications taken currently or in the past 7 days Take 1-2 of these medications currently or in past 7 days Takes 3-4 of these medications currently or in past 7 days Add one point, if patient had a change in these meds or dose in past 5 days Parameter H. Predisposing Diseases Score 0 2 4 0 1 1 1 1 Patient Status/Condition None present 1-2 present 3 or more present No risk factor Oxygen Tubing Inappropriate or patient does not consistently use device Equipment needs Other: Bases upon the following conditions: hypertension, vertigo, CVA, parkinson's diseases, loss of limbs, seizures. Arthritis, osteoporosis fracture. TOTAL SCOREA score of 10 or more indicated High Risk for falls.The patient/patient representative has been informed about the fall risk assessment results and safety/fall prevention recommendation. Yes No Name First Last Patient's representative signatureDate MM slash DD slash YYYY Name of RN:Date MM slash DD slash YYYY