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.)
E.
Gait and Balance
0
1
1
1
1
1
1
0
Orthostatic
Changes
F.
2
4
Normal/safe gait and balance.
Balance problem while standing,
Balance problem while walking.
Decreased muscular coordination.
Change in gait pattern when walking through doorway.
Jerking or unstable when making turns.
Requires assistance (person, furniture/walls or device).
No noted drop in blood pressure between lying and standing.
No change to cardiac rhythm.
Drop<20mmHg in BP between lying and standing.
Increase of cardiac rhythm <20.
Drop >20mmHg in BP between lying and standing.
Increase of cardiac rhythm>20.
Based upon the following types of medications: anesthetics, antihistamines, cathartics,
diuretics, antihypertensive, antiseizure, benzodiazepines, hypoglycemic, psychotropic,
sedative/hypnotics.
G.
Medications
0
2
4
1
H.
Predisposing
Diseases
I.
Equipment Issues
TOTAL SCORE
None of these medications taken currently or w/in past 7 days.
Takes 1-2 of these medications currently or w/in past 7 days.
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
doses in past 5 days.
Based upon the following conditions: hypertension, vertigo, CVA, Parkinsons Disease, loss
of limb(s), seizures, arthritis, osteoporosis, fractures.
0
2
4
0
1
1
1
1
None present
1-2 present
3 or more present
No risk factors noted
Oxygen tubing
Inappropriate or client does not consistently use assistive device.
Equipment needs:
Other:
Score of 8 to 14
= Moderate risk for falls
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
Signature of RN
No
Date (Month, day, year)
Addressograph
Time
If Fall Risk Score of 8 or greater:
Intervention already ordered.
Patient has been assessed by this department within last 30 days.
Patient refused additional intervention.
Comments: ____________________________________________________________________________________
________________________________________________________________________________________________
Signature of RN
Date (Month, day, year)
Time
FALL RISK ASSESSMENT ALGORITHM
FALL RISK SCORE OF 8
OR GREATER
ADDITIONAL SERVICES
TO BE CONSIDERED
-Impaired Mobility
-i -History of Falls
-Predisposing DX
-Weakness
-Knowledge Deficit
or noncompliance
with activity
restrictions
P.T.
-Pt demo unsafe
behavior or choices
-ADL Deficits
-Sensory Deficits
-Decreased Cognition
-Unsafe living
environment
-UE limitations
Nursing
Observation
Interventions
O.T.
-Elimination Deficit
-Medication Issues
-Predisposing DX
-Uncontrolled pain
-Medical instability
or decline
-Incontinence
IMC
-ADL Deficit
-Elimination Deficit
-Impaired Mobility
Attendant
Additional Services Requested:
P.T.
Nursing Observation Interventions
O.T. IMC Attendant Other: __________
Comments:___________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
MD Signature: ______________________________________ Date: ___________________ Time: ___________
