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Post Fall Assessment
Consumer Name
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Date of Current Fall
*
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IR Reference#
*
Have you had any falls within that 6 months?
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Yes
No
How many falls
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Date of Fall Within last 6 months?
*
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Fall within last 3 months
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Yes
Date fall in last 3 months
*
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Where did the fall occur?
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Basement
Bedroom
Bathroom
Kitchen
Living room/Front room
Lobby/Entry
Stairs (inside)
Stairs (outside)
Dining room
Away from the home
Where did the fall take place?
*
Description of the fall:
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Do you require the use of an assistive device?
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Yes
No
Type
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Cane
Scooter
Walker
Wheelchair
At the time of the fall, where you using your assistive device?
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Yes
No
Action Taken Following the Fall
*
ER Visit, Urgent Care, or other Medical Facility
Notify your physician
Did or are you having any of the following symptoms as a result of the fall?
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Dizziness
Headaches
Soreness/Stiffness
Increased Pain
Unusual Pain
Inability to ambulate
Difficulty dressing
Any other abnormal symptoms
Result of fall:
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Abrasions
Contusions
Lacerations
Possible Fracture
Possible Dislocation
Visual Impairments
*
Corrective Lenses
Glaucoma
Macular degeneration
Retinopathy
Type of Corrective Lenses
*
Bifocals
Trifocals
Neither
Date of Last Eye Exam
*
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Deficits and/or Intrinsic Contributing Factors:
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Balance & Gait
Medications
Cognitive
Cardiovascular
Incontinence
Balance & Gait Details
*
Stroke (disease)
Parkinsonism
Arthritic changes
Neuropathy
Neuromuscular disease
Vestibular disease
Medication Details - Use of:
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Cardiovascular medications
Opoids
Sedatives
(Polypharmacy) 4 or more medications taken at one time.
Time last medication taken before the fall occurred?
*
A.M./P.M.
*
A.M.
P.M.
Cognitive deficits present:
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Dementia
Other
Cardiovascular
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Orthostatic hypotension
Postprandial hypotension
Carotid sinus syndrome
Neurocardiogenic syncope
Cardiac arrhythmias
Incontinence
*
Urinary
Bowel
Extrinsic Factors Potentially Related to Fall
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Poor lighting/luminance
Eyesight deterioration
Stairs with inadequate handrails
Stairs too steep
Loose Rugs/tripping hazards
Clothing/footwear poorly fitted
Shoes of low friction against floor.
Lack of equipment/aids and/or assistive devices
I have provided the following interventions to minimize/avoid fall risks
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Educate patient on ways to move slowly.
Obtain supportive shoes or non-skid shoes
Remove clutter, wires, cords, scatter rugs and extraneous furniture from pathways
Encourage use of handrails in hallway, stairwells, and bathrooms.
Keep bed height in low position.
Review safe use of mobility aids (i.e, walkers, braces, and prosthetics)
Keep areas well lighted.
Accompany and keep close contact to client when in unfamiliar areas.
Avoid ambulation after medications.
Educate and re-orient patient to environment due to low vision.
Encourage individuals with corrective lenses to wear them.
Schedule an eye exam as soon as possible.
Recommended Physical Therapy - (Aetna Medicare Only)
I have assessed the above patient and made the following recommendation
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Patient may resume visits as scheduled. I will notify his/her nurse. The patient shall be monitored for the next 30 days through the agency fall monitoring program.
The patient should seek immediate medical attention.
Notes
RN Conducting Fall Assessment
*
Date
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Fall Monitoring End Date (30 Days)
*
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