Was there a history of falling? (immediate or within 3 months)

Was there a secondary diagnosis?

What ambulatory aid used?

Was there an intravenous apparatus or a heparin lock inserted?

How was the patient's gait or transferring mode?

What is the mental status of the patient?


Risk Rating Reference:
• Look at the total score above and select the relevant risk level.

risk level.PNG

Overall Risk Rating

Attending Nurse's Full Name and Signature