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Audit

Age

Patient age > 60 years?

Previous Falls

One/more in the previous year

Medication

Review current medication

Four or more (excluding vitamins)

Any psychotropic

Vision

Examine for glaucoma, cataracts, and suitability of spectacles

Low contrast visual acuity test

Peripheral Sensation

Check for diabetes

Tactile sensitivity test (Unable to feel 2 out of 3 trials)

Strength/Reaction

Near tandem stand test (Unable to stand for 10 secs)

Alternate step test (Unable to complete in 10 secs)

Sit to stand test (Unable to complete in 12 secs)

Completion

Refer to the scores above to get the Fall Risk Probability Rating:

•Low: 1-2 risk factors
•Medium: 3-5 risk factors
•High: 6 and above risk factors

Fall Risk Probability Rating:

Recommendations

Attending Nurse's Full Name and Signature

General Patient Fall Risk Assessment Template Checklist

Created by: SafetyCulture Staff | Industry: General |

This fall risk assessment template is used to evaluate a patient’s probability of falling. It includes fields to record a patient’s fall history, current medication, and medical test results (vision, peripheral sensation, and mobility). Record the patient’s fall risk rating depending on the number of accumulated risk factors. If a patient gets 1-2 risk factors patient has a Low risk probability of falling, a Medium risk for 3-5 risk factors and High risk for 6 risk factors and above.

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

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Audit

Age

Patient age > 60 years?

Previous Falls

One/more in the previous year

Medication

Review current medication

Four or more (excluding vitamins)

Any psychotropic

Vision

Examine for glaucoma, cataracts, and suitability of spectacles

Low contrast visual acuity test

Peripheral Sensation

Check for diabetes

Tactile sensitivity test (Unable to feel 2 out of 3 trials)

Strength/Reaction

Near tandem stand test (Unable to stand for 10 secs)

Alternate step test (Unable to complete in 10 secs)

Sit to stand test (Unable to complete in 12 secs)

Completion

Refer to the scores above to get the Fall Risk Probability Rating:

•Low: 1-2 risk factors
•Medium: 3-5 risk factors
•High: 6 and above risk factors

Fall Risk Probability Rating:

Recommendations

Attending Nurse's Full Name and Signature