Nursing fall risk assessment form

For high-risk patients, implement hourly rounding, ensure the call light is within reach, and use bed/chair alarms. It’s also important to maintain the bed in low position with brakes locked and provide non-slip footwear. You can consider one-to-one supervision when necessary. Document these interventions in the action plan section and communicate them to all care team members for consistent implementation.

Medications like sedatives, antidepressants, antihypertensives, diuretics, and hypoglycemic agents significantly increase fall risk through effects such as dizziness, orthostatic hypotension, or altered mental status. When completing the medication section of the assessment, review the patient’s complete medication list and consider both individual drugs and potential interactions that might compromise balance or alertness.

Document specific interventions tailored to the identified risk factors, including environmental modifications, patient education provided, mobility assistance requirements, and monitoring frequency. Also note who is responsible for implementing each intervention and when follow-up assessments should occur. This creates accountability and ensures continuity of care across shifts.

Complete a new assessment whenever there’s a change in condition and compare scores chronologically. Keep previous assessments in the patient’s record to establish trends and evaluate the effectiveness of interventions. This documentation helps demonstrate your diligence in fall prevention and supports adjustments to the care plan as the patient’s condition evolves.