Note: This form has been filled out with information for the sample case study patient, Mrs. P.
Resident: _______________Mrs._P________________________ Room: ______401-A________
Directions: Monitor staff implementation and effectiveness of the Fall Intervention Plan each week. Revise interventions as needed and record below. Use one sheet for every 2 weeks.
| Date: 4/19/04 | Date: 4/19/04 | ||
|---|---|---|---|
| Medications |
Are interventions effective: _X_ Yes ___ No Changes: Comments: Pt [Patient] adjusting to new environment. Agitation decreased |
Medications |
Are interventions effective: ___ Yes _X_ No Changes: Comments: Pt with occasional periods of agitation. |
| Orthostatic Hypotension |
Are interventions effective: ___ Yes ___ No Changes: Comments: NA |
Orthostatic Hypotension |
Are interventions effective: ___ Yes ___ No Changes: Comments: NA |
| Vision |
Are interventions effective: ___ Comments: NA |
Vision |
Are interventions effective: ___ Yes ___ No Changes: Comments: NA |
| Mobility |
Are interventions effective: _X_ Yes ___ No Changes: Comments: Staff Assisting with all transfers |
Mobility |
Are interventions effective: _X_ Yes ___ No Changes: Comments: |
| Unsafe Behavior |
Are interventions effective: ___ Yes _X_ No Changes: Comments: Pt needs toileting 1-1½ hrs instead of 2 hrs. |
Unsafe Behavior |
Are interventions effective: _X_ Yes ___ No Changes: Medicate with analgesic as ordered. Comments: Monitor agitation in conjunction with analgesic effectiveness. |
Signature: ___________Susan_Brown_LPN_______________ Date: _______4/19/04_____________
