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Medicare fall risk assessment form

Medicare fall risk assessment form

Ensure compliance with medicare guidelines using this fall risk assessment form. It helps evaluate patient risk factors and document preventive strategies. Use this form to meet regulatory requirements and enhance patient safety.

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Medicare fall risk assessment form

Ensure compliance with medicare guidelines using this fall risk assessment form. It helps evaluate patient risk factors and document preventive strategies. Use this form to meet regulatory requirements and enhance patient safety.

Use this template with Lumiform

  • Customize this template or build your own
  • Fill out templates via mobile app
  • Get reports and analyse your data
Prices start from ░░░ per month
Book a demo
Learn more
or Download template as PDF

The Medicare fall risk assessment form allows you to quickly identify patients at risk for falls through targeted questions about fall history, medication use, and home environment safety. The US Centers for Disease Control and Prevention reports that falls are the top cause of injury for adults 65 and older, and over 1 in 4 older adults report falling every year.

With this form, you can streamline the assessment process required during Medicare wellness visits. You can then better meet compliance requirements while developing effective fall prevention strategies. For example, when a patient indicates they take multiple medications and lack bathroom grab bars, you can immediately prioritize medication review and home modification recommendations.

Related categories

Preview of the template
Page 1
Patient History
Have you fallen in the past year?
Do you feel unsteady when walking?
Do you worry about falling?
Medication Review
Are you taking 4 or more medications?
Are you taking any medications that could increase your risk of falling (e.g. sedatives, antidepressants)?
Environmental Assessment
Are there throw rugs in your home?
Is your home well-lit, with good lighting especially on stairs?
Do you have grab bars in your bathroom?

Frequently asked questions

How can I use this Medicare fall risk assessment form in my practice?

This form helps you conduct standardized fall risk screenings during Medicare wellness visits. Simply walk through each section with your patient, marking their responses. The yes/no format makes it easy to quickly identify risk factors across patient history, medications, and home environment. After completion, use the results to develop personalized fall prevention recommendations and document the assessment for Medicare compliance.

When should I administer this fall risk assessment to my Medicare patients?

Administer this assessment during the Welcome to Medicare preventive visit, Annual Wellness Visits, or when patients report a fall or express concerns about balance. It’s also appropriate when you observe unsteady gait or when patients start new medications that might affect balance. Regular assessments help identify changes in risk status before falls occur.

How do I interpret the results of this Medicare fall risk assessment?

Each “yes” answer indicates a potential risk factor. Multiple “yes” responses in any section suggest higher risk in that domain. For example, three “yes” answers in patient history indicate high risk based on past experiences. Medication and environmental “yes” answers highlight specific modifiable factors you can address through interventions.

What follow-up actions should I take based on the assessment results?

For patients with multiple “yes” responses, consider referrals to physical therapy for gait training, medication review by a pharmacist, or home safety evaluation. Document both the assessment findings and your follow-up plan in the patient’s record. Schedule a follow-up visit to evaluate the effectiveness of interventions and reassess risk factors.

This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.