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The Falls Management Program

Fall Interventions Monitor (Text Version)

Note: This form has been filled out with information for the sample case study patient, Mrs. P.

Resident: _______________Mrs._P________________________   Room: ______401-A________

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: 4/19/04   Date: 4/19/04
Medications

Are interventions effective: _X_ Yes ___ No

Changes:

Comments: Pt [Patient] adjusting to new environment. Agitation decreased

Medications

Are interventions effective: ___ Yes _X_ No

Changes:

Comments: Pt with occasional periods of agitation.

Orthostatic Hypotension

Are interventions effective: ___ Yes ___ No

Changes:

Comments: NA

Orthostatic Hypotension

Are interventions effective: ___ Yes ___ No

Changes:

Comments: NA

Vision

Are interventions effective: ___
Yes ___ No
Changes:

Comments: NA

Vision

Are interventions effective: ___ Yes ___ No

Changes:

Comments: NA

Mobility

Are interventions effective: _X_ Yes ___ No

Changes:

Comments: Staff Assisting with all transfers

Mobility

Are interventions effective: _X_ Yes ___ No

Changes:

Comments:

Unsafe Behavior

Are interventions effective: ___ Yes _X_ No

Changes:

Comments: Pt needs toileting 1-1½ hrs instead of 2 hrs.

Unsafe Behavior

Are interventions effective: _X_ Yes ___ No

Changes: Medicate with analgesic as ordered.

Comments: Monitor agitation in conjunction with analgesic effectiveness.

Signature: ___________Susan_Brown_LPN_______________   Date: _______4/19/04_____________

Return to Appendix C

 

AHRQ Advancing Excellence in Health Care