Post Fall Assessment
Date of Current Fall
Have you had any falls within that 6 months?
How many falls
Date of Fall Within last 6 months?
Fall within last 3 months
Date fall in last 3 months
Where did the fall occur?
Living room/Front room
Away from the home
Where did the fall take place?
Description of the fall:
Do you require the use of an assistive device?
At the time of the fall, where you using your assistive device?
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?
Inability to ambulate
Any other abnormal symptoms
Result of fall:
Type of Corrective Lenses
Date of Last Eye Exam
Deficits and/or Intrinsic Contributing Factors:
Balance & Gait
Balance & Gait Details
Medication Details - Use of:
(Polypharmacy) 4 or more medications taken at one time.
Time last medication taken before the fall occurred?
Cognitive deficits present:
Carotid sinus syndrome
Extrinsic Factors Potentially Related to Fall
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
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
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.
RN Conducting Fall Assessment
Fall Monitoring End Date (30 Days)