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    4 Fall Risk Assessment Template

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    0811683919
    fall risk

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    4 Fall Risk Assessment Template

    Uploaded by

    0811683919
    205 views3 pages
    fall risk

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    © © All Rights Reserved

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    DOCX, PDF, TXT or read online from Scribd

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    fall risk

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    205 views3 pages

    4 Fall Risk Assessment Template

    Uploaded by

    0811683919
    fall risk

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    Fall Risk Assessment—Part 1

    Fall Risks Findings Recommended Actions


    1. a. Ask patient if he or Describe patient reliability in reporting and nature of o If the patient has not fallen in
    she has fallen in the past fears/balance issues: the past year and reports no
    year. fear or balance issues and is
    1. b. If the patient has not otherwise a good historian,
    fallen in the past year, ask no further assessment may
    if he or she fears falling or need to be performed.
    has difficulty walking or has o If the patient does fear falling
    balance issues. or reports difficulty with
    walking or balance, continue
    to screen for fall risk.

    2. If the patient has fallen Describe frequency and circumstances: o If the patient fears falling due
    in the past year (or is to difficulty walking or has
    fearful of falling or reports balance issues, but has not
    difficulty with walking and fallen or has only had a
    balance), ask how single fall, patient should
    frequently the patient has have an assessment of gait
    had difficulty or has fallen, and balance (see below).
    and under what o If the patient has had
    circumstances these recurrent falls in the past
    events occurred. year, he or she should have
    a multifactorial fall risk
    assessment performed by a
    clinician with appropriate
    skills and training
    3. If the patient cannot Describe results of test: o If the patient has had only a
    perform or performs poorly single fall, fears falling, or
    on the standardized gait reports difficulty with walking
    and balance test, or and balance but has no
    demonstrates unsteadiness difficulty or unsteadiness
    during the test, he or she during the gait and balance
    should have a multifactorial assessment, he or she may
    fall risk assessment not need a multifactorial fall
    performed. risk assessment. The CC
    should apply professional
    judgment in making this
    determination.

    Fall Risk Assessment—Part 2

    Screening for gait instability performed using the “Timed Get Up and Go” test

    Section 4.17.4 Implement–Fall Risk Assessment Template - 1


    Fall Risk Assessment—Part 2

    Screening for gait instability performed using the “Timed Get Up and Go” test

    1. Prior to conducting the test:


     Place a marker ten feet from a standard armchair.
     Encourage the patient to wear regular footware, use any customary walking aid, and walk normally.
     No physical assistance should be given.
     Have the patient walk through the test once before being timed to become familiar with the test.
     Explain to the patient that he or she will be asked to perform the test three times and will be timed (from the
    point the patient rises out of the chair to the time the patient sits down).

    2. To test the patient, give the following instructions:


    1. Rise from the chair
    2. Walk to the mark on the floor (10 feet away)
    3. Turn
    4. Return to the chair
    5. Sit down

    3. Record time for each test:


    Test 1: _____ seconds
    Test 2: _____ seconds
    Test 3: _____ seconds

    4. Record patient’s mobility based on the following scale:


     <10 seconds = Freely mobile
     10-20 seconds = Mostly independent, consider further evaluation
     >20 seconds = Variable or impaired mobility, a multifactorial fall risk assessment should be peformed

    5. For patients who are not referred for a multifactorial fall risk assessment, the following strategies are further useful
    for reducing the risk of falls:
     Conduct an Environmental Risk Assessment and recommend adaptations or modifications accordingly.
     Conduct a Medication Reconciliation Assessment and determine if there are psychoactive or other medications
    that the patient’s primary care provider may want to consider withdrawing or recommend minimal use. Fall risk
    may not have been assessed during an outpatient visit or may have changed since the last visit.
     Determine if there is need for postural hypotension management. Discuss with patient’s primary care provider.
     Determine if there are foot problems that need management. Discuss with patient’s primary care provider if a
    referral to a podiatrist may be helpful.
     Recommend balance, strength, and gait training exercise. Discuss with patient’s primary care provider if there
    is need for any specialized therapy.

    Section 4.17.4 Implement–Fall Risk Assessment Template - 2


    Copyright © 2014 Stratis Health and KHA REACH. Updated 01/05/2015

    Section 4.17.4 Implement–Fall Risk Assessment Template - 3

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