Oxygen Therapy:

Trach:

Growth and Development:

Mental Status:

Seizures:

Eyes:

Ears:

Nose:

Bowel Sounds:

Last BM:

Mouth:

Throat:

Colostomy/Ileostomy:

Skin:

Mucus Membranes:

Catheter:

Urination:

Dialysis:

If the total score of the items above is 3 or greater, or based on clinical judgement, initiate the Fall Prevention Program in the Plan of Care.

Scoring Criteria:

1. Clinical Judgement Patient diagnosis or condition warrants fall prevention program.
2. Mobility Uses assistive devices or needs assitance for ambulance/transfer. Evidence of generalized weakness or decreased mobility in lower exremities, poor balance and dizziness.
3. Mentation Patient is developmentally delayed or is disoriented.
4. Elimination Has need to get to toilet frequently or urgently. Needs assistance with toileting.
5. History of Falls related to Illness Has the patient fallen within the last year related to illness, including falls at home or a previous admission or during this admission? (refer to inpatient admission assessment).
6. Current Medications Anticonvulsants, opiods, benzodiazepines. Also consider diuretics, antihypertensives, and analgesics, bowel preps.

Homebound Status:

Limited ROM:

Rehabilitation Potential/Goals:

Nursing:

Home Health Aide:

Physical Therapy:

Speech Therapy:

Occupational Therapy:

Medical Social Services: