Text Description
Resident: ____________________________________________ Room: ____________________
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 |
|---|---|
|
___ Primary Care Provider Report faxed |
|
| Medications
___ Antipyschotics |
___ Medication review by consultant pharmacist |
| 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 |
| Mobility
___ Unsafe during the Get Up and Go Test |
___ OT consultation |
| Unsafe Behaviors
___ Tries to stand, transfer, or walk alone unsafely |
___ Behavioral assessment |
Signature: _______________________________ Date Completed: ________________________
