Falls Assessment Report (Text Version)
Note: This form has been filled out with information for the sample case study patient, Mrs. P.
Facility: _______Greystone_Manor____________________
Address: _________1254_Martin Lane________________
City/State: ______Wilkes,_TN_04321_________________
Telephone: ______(423)_403-4881___________________
Fax: ______(423)_403-3312________________________
Date: ____4_____ / _____4____ / ____04____
Resident Name: ___________Mrs._P______________________
Findings: (X) = positive for this resident |
Suggestions for further assessment and/or interventions |
(X) Medications that could increase fall risk:
Ativan 1 mg PRN
Zoloft 50 mg QD Paxil 40 mg QD
|
- Review medications and consider changes if appropriate.
- Consider psychiatric evaluation if indicated to evaluate psychotropic meds
- Consider consultant pharmacist recommendations.
|
( ) Low vision |
- Consider optometry or ophthalmology evaluation.
|
( ) Postural hypotension
≥20 mm Hg drop in systolic pressure with position change |
- Review cardiovascular and diuretic medications.
- Consider blood work for BUN/Creatinine ratio.
- Consider TED hose.
|
(X) Unsafe gait, transfers, and/or wheelchair seating problems |
- Consider OT/PT evaluation.
|
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