• Document No.

  • Conducted on

  • Hospital

  • Ward

  • Bed number

  • Acknowledgement: Based on the Queensland Health paper tool available at

  • This audit collects patient level data on a ward/unit. Start a new audit for each patient audited.

    If an unwanted media field opens, tap the relevant question to close it.

    Please maintain patient confidentiality at all times.

Observational audit - patient

  • Which type of bed rail is present on the bed? (Note: only check where a patient is present.)

  • Is the nurse call system within reach of the patient?

  • Is the bed control (if bed has a control) within reach of the patient?

  • Is the patient's bed at the appropriate height? Note: Appropriate height is the level that the patient can sit and touch the floor with their feet, with their legs at 90 degrees.

  • Are the patient's bed brakes locked on?

  • Is the patient's chair at the appropriate height?

  • Is the patient's room free of clutter / other hazards?

  • Is the patient's tray table within reach?

  • If the patient has sensory aids (eg glasses, hearing aid) are they within reach?

  • Does the patient have appropriate footwear? (Eg non-slip / well fitting / low heel)

  • If patient is at risk of falling, are they within view of and close to the nursing station? (Risk is determined below.)

  • If "no" responses are obtained, advise Nurse so that the problem can be promptly rectified.

Documentation audit - patient

  • Is there documented evidence at the bedside that the patient was screened for a history of falling on admission?<br>(Note: screening identifies if the patient is at increased risk of falling and then should be assessed at admission.)

  • Is there documented evidence at the bedside that the patient was assessed for risk of falling on admission?

  • What is the patient's documented risk of falling?

  • What type of bed is the patient in?

  • If the patient is at risk of falling, have they been reviewed by the Physio / OT?

  • Which one?,

  • Is there documented evidence at the bedside that there is a multifactorial falls prevention plan (FPP)?<br>(Ie documented actions corresponding to identified risk factors.)

  • What type of bed is the patient in?

  • Is there documented evidence at the bedside of the level of supervision / assistance required for mobilisation in the patient's care plan? (Red dot system.)<br>(N/A for patients that can mobilise independently.)

  • Is there documented evidence at the bedside that the patient's care plan includes the use of a mobility aid?<br>(N/A for patients that can mobilise independently.)

  • Is the mobility aid within arms reach of the patient? (Patient refuses to use aid = PRTUA)

  • Does the patient have documentation at the bedside (ie in the care plan) that an assessment has been undertaken for continence and continence aid requirements?

  • Has the discharge process commenced?

  • Have referrals to appropriate primary health providers / community services been organised?

  • To whom - select all applicable options

  • Specify what other referrals have been made.

  • Is there evidence that the patient has experienced a fall while in hospital?

  • Is there evidence the incident has been entered into the incident management system (EIMS)?

  • Report to NUM to ensure incident is recorded.

Patient Questions

  • Patient Q: We're you shown around the bed area, room and ward/unit facilities on admission?

  • Patient Q: Did you have an education session with a staff member on how you can prevent falls?

  • Which form of education did you receive?

  • Patient Q: Were you involved in the development of plans to prevent you falling while in hospital?

  • If you have identified a patient risk related to bed or surrounds, please photograph here (do not include any patient faces in the photo).

  • Auditor please enter your name and sign off here

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