Interdisciplinary Post-Fall Assessment
General Information:
Resident:
Date:
Unit:
Room:
Diagnoses:
Time of Fall:
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Day shift
Eve shift
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Night shift
Resident’s lifelong habits:
Equipment used: Please check all that apply
 Tabs monitor  Bed/Chair monitor
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Specialized seating system
 Bed bars  Bolsters  Seat belt 
 Side rails:  Both up  Half up  One up
Description and Type of Fall: Please check all that apply
Falls from Bed
While Sitting
While Transferring
 Reached for object  Slid out of WC
 In/out of Bed
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Rolled out of bed
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Other:
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Tipped WC:
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Forward
Backward
While Ambulating
 Loss of balance
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Chair
Mat
Other:
Nursing Assessment: Please check all that apply
Cognitive
Neurological
 Dementia
 CVA
Cardiovascular
 Arrhythmia
Urinary
 UTI
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Delirium
Depression
Confusion
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Peripheral disease
Parkinson’s
Brain pathology
Ischemia
HTN
Hypotension
Wedge cushion
Faintness/Dizziness
Fatigue
Tripped over object
Other:
Foot Disorders
 Bunions
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Incontinence
Nocturia
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Frequency
Deformities
Decreased sensation
Other:
Head injury
Medication
 Cardiovascular
Orthopedic
 Joint Pain
Sensory
 Visual
Respiratory
 COPD
Extrinsic/Environmental
 Change of shift
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Psychoactive
Sedative/hypnotic
GI Medication
Recent PRN
Diuretics
THR
TKR
Amputation
Hearing
Touch
Other:
Other:
Unsteady gait
Osteoporosis
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Cause:
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Risk:
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Complication:
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Rehab potential:
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Care plan updated (attach copy of updated care plan)
Nurse signature:
Pneumonia
Date:
Lighting
Furniture
Moderate activity
Clothing
Flooring
Call bell
Minimal activity