Appendix B12: Fall Interventions Monitor

The Falls Management Program Manual

Text Description

Resident: _____________________________________________   Room: ____________________

Directions: Monitor staff implementation and effectiveness of the Fall Intervention Plan each week. Revise interventions as needed and record below. Use one sheet for every 2 weeks.

 Date: Date:
Medications

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

Medications

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

Orthostatic Hypotension

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

Orthostatic Hypotension

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

Vision

Are interventions effective: ___
Yes ___ No
Changes:

Comments:

Vision

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

Mobility

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

Mobility

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

Unsafe Behavior

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

Unsafe Behavior

Are interventions effective: ___ Yes ___ No

Changes:

Comments:

Signature: _________________________________________   Date: ___________________________

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Figure 22 Image

Current as of December 2012
Internet Citation: Appendix B12: Fall Interventions Monitor: The Falls Management Program Manual. December 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/fallspxmanapb6txt.html