Fall Risk Assessment Guidelines
Patient name:_____________________________________ Date:__________________________________________
Patient room number:______________________________ Admission date:__________________________________
Assessor name:_____________________________________________________________________________________
Circle appropriate numbers below and repeat this assessment every 6 months, unless score is ≥8, which requires quarterly assessments.
History of Falls
Ambulation Status (circle one): Up Bed Walker Wheelchair Sensory deficits
1-2 falls in a month/quarter 2 points Decreased hearing: 1 point
>2 falls in a month/quarter: 8 points Vision: 1 point
Fall-related fracture (list date):_______ 5 points Aphasia: 1 point
Conditions Unsteady or shuffling gait: 2 points
Postural hypotension (orthostasis): 1 point Confusion/delirium/disorientation: 2 points
Syncope/dizziness: 1 point Agitation/increased anxiety: 2 points
Total:________________________________
Medications
Each medication is 1 point: Each medication is 2 points:
Anticonvulsants Antidepressants or antihistamines (H1 or H2 blockers)
Antihypertensives Antipsychotics or metoclopramide
Antiparkinson agents Anxiolytics
Cardiac medications Central nervous system stimulants
Diuretics Hypnotics
Mild narcotic analgesics Moderate to most potent narcotic analgesics
Muscle relaxants
Nonsteroidal anti-inflammatory drugs
Subtotal: Subtotal:
Total:
Diagnoses
Cardiac/Hematologic Neurologic/Psychiatric Musculoskeletal Incontinence
Diseases (1 point each) Diseases (1 point each) Diseases (1 point each) (2 points each)
Anemia Dementia Arthritis casts/splints/slings Bowel
Arrhythmias Parkinsonism Prosthesis Bladder
Congestive heart failure Seizures
Stroke
Subtotal: Subtotal: Subtotal: Subtotal:
Total:
Add totals for history of falls, medications, and diagnoses for total score. Total Score: __________________
Risk Ranges: Minimal: 0-3 points Moderate: 4-7 points High risk: ≥8 points
If total is ≥8, reassess every quarter and state interventions planned:_____________________________________________
________________________________________________________________________________________________
Medication Changes:________________________________________________________________________________
Emergency Department Visits/Hospitalization Date(s) and Reasons (include total fall risk scores for those dates):__________
________________________________________________________________________________________________
Signature of Assessor:________________________________________________________ Date:___________________
Please use in your practice to assess falls risk. Permission to copy and distribute this document is hereby granted provided that this notice is retained
on all copies, that copies are not altered, and that Annals of Long-Term Care, a property of HMP Communications, is credited as the source.
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Assessment tool developed by Allison H. Burfield, RN, MSN, PhD, University of North Carolina, Charlotte; and James W. Cooper, RPh, PhD, BCPS, The University of
Georgia College of Pharmacy, Athens. Earlier versions of “Fall Risk Assessment Guidelines” previously published by authors in Nursing Home Pract. 1994;2(6):28-30.
