Note: This form has been filled out with information for the sample case study patient, Mrs. P.
Resident: _____________Mrs._P_________________________ Room: ____401-A__________
Directions: Use the instructions on the Falls Assessment Cue Sheet to assess the resident in the five areas listed in the first column. Put a check beside each risk factor present for this resident. If the resident does not have a risk factor, put a check beside N/A. In the second column, check when the primary care provider report is faxed and orders are received and when the resident is discussed in the interdisciplinary team meeting. Check all appropriate evaluations and referrals. Once the assessment is complete, proceed to the Fall Interventions Plan and select specific individualized interventions for each risk category identified for this resident.
| Risk Factors | Interdisciplinary Assessments |
|---|---|
| _X_ Primary Care Provider Report faxed _X_ Primary Care Provider Orders received ___ Discussed in falls team meeting |
|
|
Medications ___ Antipyschotics |
_X_ Medication review by consultant pharmacist ___ Psychiatric evaluation |
|
Orthostatic Hypotension ___ Reduction of ≥20 mm Hg in systolic pressure 1 minute after change in position from sitting to standing |
___ Review cardiovascular medications |
|
Vision ___ Stumbles and trips |
___ Optometrist evaluation ___ Ophthalmologist referral |
|
Mobility _X_ Unsafe during the Get Up and Go Test |
___ OT consultation _X_ PT consultation |
|
Unsafe Behaviors _X_ Tries to stand, transfer, or walk alone unsafely |
_X_ Behavioral assessment ___ Evaluation of restraint use |
Signature: ____Susan_Brown_LPN___________________________ Date Completed: ____4/3/04________
