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.)
0 Normal/safe gait and balance.
1 Balance problem while standing,
E. Gait and Balance 1 Balance problem while walking.
1 Decreased muscular coordination.
1 Change in gait pattern when walking through doorway.
1 Jerking or unstable when making turns.
1 Requires assistance (person, furniture/walls or device).
No noted drop in blood pressure between lying and standing.
0
No change to cardiac rhythm.
Orthostatic Drop<20mmHg in BP between lying and standing.
F. 2
Changes Increase of cardiac rhythm <20.
Drop >20mmHg in BP between lying and standing.
4
Increase of cardiac rhythm>20.
Based upon the following types of medications: anesthetics, antihistamines, cathartics,
diuretics, antihypertensive, antiseizure, benzodiazepines, hypoglycemic, psychotropic,
sedative/hypnotics.
0 None of these medications taken currently or w/in past 7 days.
G. Medications 2 Takes 1-2 of these medications currently or w/in past 7 days.
4 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
1
doses in past 5 days.
Based upon the following conditions: hypertension, vertigo, CVA, Parkinsons Disease,
loss of limb(s), seizures, arthritis, osteoporosis, fractures.
Predisposing 0 None present
H.
Diseases 2 1-2 present
4 3 or more present
0 No risk factors noted
1 Oxygen tubing
I. Equipment Issues 1 Inappropriate or client does not consistently use assistive device.
1 Equipment needs:
1 Other:
Score of 8 to 14 = Moderate risk for falls
TOTAL SCORE 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 □ No
Signature of RN Date (Month, day, year) Time

Addressograph
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 -Pt demo unsafe -ADL Deficits -Elimination Deficit -ADL Deficit
-i -History of Falls behavior or choices -Sensory Deficits -Medication Issues -Elimination Deficit
-Predisposing DX -Decreased Cognition -Predisposing DX -Impaired Mobility
-Weakness -Unsafe living -Uncontrolled pain
-Knowledge Deficit environment -Medical instability
or noncompliance -UE limitations or decline
with activity -Incontinence
restrictions

O.T.
P.T. Nursing IMC Attendant
Observation
Interventions

Additional Services Requested:

□ P.T. □ Nursing Observation Interventions □ O.T. □ IMC □ Attendant □ Other: __________

Comments:___________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

MD Signature: ______________________________________ Date: ___________________ Time: ___________