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Nursing fall risk assessment form

Nursing fall risk assessment form

A comprehensive form for evaluating patient fall risk factors and documenting targeted prevention strategies in healthcare settings.

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The Lumiform application helps frontline teams uphold internal standards effortlessly.
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Nursing fall risk assessment form

A comprehensive form for evaluating patient fall risk factors and documenting targeted prevention strategies in healthcare settings.

Use this template with Lumiform

The Lumiform application helps frontline teams uphold internal standards effortlessly.
  • Customize this template or build your own
  • Fill out templates via mobile app
  • Assign and track corrective actions
  • Get reports and analyse your data
Prices start from ░░░ per month
Book a demo
Learn more
or Download template as PDF

Our nursing fall risk assessment form helps you identify patients at high risk for falls and implement targeted preventive measures. This tool evaluates key risk factors including medication use, mobility status, and cognitive function—providing an organized approach to fall prevention in healthcare settings.

According to the US Centers for Disease Control and Prevention (CDC), more than 25% of older adults fall annually, with more than half not reporting these incidents to healthcare providers. This template allows you to document fall risk systematically, calculate a risk score, and develop an action plan with specific interventions and follow-up protocols.

Related categories

  • Health and safety management templates
  • Health care templates
  • Risk assessment templates
Preview of the template
Page 1
Patient Information
Patient Name
Patient ID
Date of Assessment
Age
Gender
Fall Risk Assessment
History of Falls (past 3 months)
Medications (sedatives, antidepressants, etc.)
Mobility
Visual/Hearing Impairment
Cognitive Impairment
Incontinence
Pain
Orthostatic Hypotension
Fall Risk Score
Total Risk Score
Action Plan
Interventions
Responsible Nurse
Scheduled Follow-up

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Related resources

Access a complete set of resources aimed at maximizing safety, quality, and operational excellence, including detailed guides, related templates, and real-world use cases.

Topic guides

Read in-depth guides covering key topics related to this article.

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Frequently asked questions

What are the most important interventions for high fall risk patients?

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.

How do medications affect fall risk assessment?

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.

What should I document in the action plan?

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.

How can I use this form to track changes in fall risk over time?

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.


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.
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