Falls Risk Evaluation & Prevention Plan Note

Date/Time: [Date and time of encounter]

Setting: [clinic / home visit / SNF / hospital consult]

Referral Source/Reason: [Reason for evaluation] (If post-acute fall, state "Falls evaluation triggered by acute fall on [date]")

Information Sources: [Primary historian(s) and reliability] (Note reliability concerns such as cognitive impairment, limited historian, or lack of records)

(For any unavailable information, document "unknown" or "not available" with the reason; do not leave blanks.)

Fall-Risk Screening Summary

[Screening method and result] (Document tool used, e.g., 3 key questions: fell in past year, feels unsteady, worries about falling)

• [Number of falls in past 12 months] (If unknown, state "unknown" and why)
• [Date of last fall]
• [Any fall requiring medical attention: yes / no]
• [Screening outcome: positive / negative]

Chief Concern

[Patient-stated concern and clinician framing] (Use a direct quote when it clarifies circumstances; include "falls risk evaluation and multifactor prevention plan" as appropriate)

History of Present Illness

Fall Events

[Index fall narrative] (Include: date/time, location, surface/lighting, footwear, assistive device use, activity before fall, mechanism, prodromal symptoms—explicitly state presence or absence of dizziness, lightheadedness, chest pain, palpitations, focal neurologic symptoms, visual changes, confusion—loss of consciousness or head strike, injuries, ability to get up, time on floor, whether medical care was sought. Include near-falls and patterns such as nocturnal, post-prandial, positional. Do not label a fall as "mechanical" unless narrative clearly supports trip/slip without concerning prodrome.)

(If multiple falls, summarize pattern briefly, then use the table below.)

Date	Circumstances	Symptoms	Injuries	Assistance needed
[Date]	[Location, surface, lighting, activity, mechanism, device use]	[Prodromal symptoms present or absent; LOC/head strike]	[Injuries sustained]	[Needed help to get up; time on floor; sought care]
[Add rows as needed]

Baseline Mobility & Function

• [Gait/transfer status: independent / needs supervision / needs assistance] (Include device(s) used and adherence/technique issues)
• [ADL/IADL impact since falls]
• [Activity avoidance and fear of falling]
• [Recent deconditioning or hospitalization]

Relevant Symptom Review

(Include only symptoms that would change workup or plan)

• [Neurologic: weakness, numbness, tremor, freezing, neuropathy]
• [Cardiac: syncope/presyncope, palpitations]
• [Vestibular: vertigo, positional triggers]
• [GU: urgency/nocturia leading to rushing]
• [Sleep: insomnia, daytime sedation]
• [Mood/Cognition: depression, confusion]
• [Vision/Hearing changes]

Medications Contributing to Fall Risk

• [Medication reconciliation status: complete / partial / not performed] (Describe gaps and steps taken to obtain missing info)
• [High-risk medications by category] (Sedatives/hypnotics, benzodiazepines, antidepressants, antipsychotics, opioids, anticonvulsants, anticholinergics, antihistamines, muscle relaxants, antihypertensives; include relevant OTCs/supplements and alcohol/substance use)
• [Patient-reported adverse effects: sedation, dizziness, confusion, orthostatic symptoms]

(For medications with planned changes, use the table below. Note shared decision-making.)

Medication	Suspected fall-risk mechanism	Recommended action	Responsible prescriber	Timeline/Monitoring
[Medication name]	[Sedation / orthostasis / impaired balance / other]	[stop / taper / switch / dose-reduce / monitor]	[Name/role]	[Follow-up and safety monitoring plan]
[Add rows as needed]

Intrinsic and Environmental Risk Factors

Vision

• [Last eye exam date]
• [Current eyewear and usage] (Note bifocal/progressive-related issues)
• [Cataracts or visual complaints; screening result if performed]

Hearing

• [Self-reported impairment]
• [Hearing aid use and adequacy]
• [Impact on balance/awareness]

Feet & Footwear

• [Foot pain, deformities, ulcers, neuropathy symptoms]
• [Usual footwear indoors/outdoors]
• [Observed footwear at visit and safety concerns]

Home/Community Safety

(For community-dwelling: address stairs/handrails, lighting, throw rugs/clutter, bathroom safety, bedroom-to-bathroom path. For facilities: address call bells, alarms, toileting plan.)

• [Environment type: private home / assisted living / SNF / other]
• [Identified hazards and status: present / addressed / planned]
• [Care coordination needs for home modifications]

Physical Examination

(Document specific findings rather than "WNL" without detail)

• General: [Appearance, acute distress, volume status]
• Cardiovascular: [Rate/rhythm, murmurs, edema, JVP]
• Neurologic: [Mental status, focal deficits, proprioception, vibration, neuropathy screening, tremor/rigidity, cerebellar]
• Musculoskeletal: [Lower extremity strength, hip/knee/ankle ROM, pain limiting gait, kyphosis]
• Feet: [Ulcers, deformities, calluses, footwear fit, sensation testing]

Functional Measures

• Timed Up & Go: [Time] sec (device: [none / cane / walker]; observations: [postural stability, stride, turning]; interpretation: [normal / elevated risk])
• 30-Second Chair Stand: [Count] reps (interpretation relative to age norms: [below / at / above])
• 4-Stage Balance: [Longest stage held: side-by-side / semi-tandem / tandem / single-leg] for [Time] sec (result: [pass / fail])
• [Observed gait description] (Include if standardized testing not performed or to supplement)

(If testing cannot be performed safely, document "not performed" with reason.)

Orthostatic Vital Signs

(Include when indicated: dizziness/presyncope, falls on standing, antihypertensive use, suspected dehydration, unexplained falls. If not performed, state "not performed" with rationale.)

Position	Time	BP	HR	Symptoms
Supine	[Duration]	[BP]	[HR]	[Present / absent; specify]
Standing	1 min	[BP]	[HR]	[Present / absent; specify]
Standing	3 min	[BP]	[HR]	[Present / absent; specify]

Assessment

Falls risk level: [low / moderate / high] (State organizational criteria and brief rationale)

Synthesis: [Fall count, mechanisms, key contributing factors, and uncertainties]

Differential diagnosis: [Orthostatic hypotension vs vestibular disorder vs medication effect vs environmental hazards vs arrhythmia vs other] (Include only if mechanism unclear)

Explicit concerns: [Syncope suspicion / head injury risk / anticoagulant use / prolonged time on floor / new focal neurologic findings] (State clearly if present or absent)

• Problem 1: [Problem name] — [Assessment and impact on injury risk]
• Problem 2: [Problem name] — [Assessment]
• (Add additional problems as needed in order of severity and modifiability)

Prevention Plan

Patient goals and preferences: [Functional goals, preferences, barriers, caregiver involvement]

Interventions by Domain

(Map each intervention to an identified risk factor; include responsible party and timeframe)

• Exercise/PT: [Referral/program; focus: strength, balance, gait training, functional transfers]
• Medication Optimization: [Stop/switch/reduce decisions with taper timelines and monitoring]
• Orthostatic Management: [Non-pharmacologic strategies, compression, position-change counseling, medication adjustments, BP goal] (Include only if orthostasis identified)
• Vision: [Eye exam referral, eyewear recommendations]
• Hearing: [Audiology referral, hearing aid optimization]
• Feet/Footwear: [Podiatry referral; footwear counseling: stable, supportive, low-heel, non-slip; discourage socks-only walking]
• Home Safety: [OT home evaluation referral; modifications: remove throw rugs, improve lighting, add grab bars, secure cords]
• Assistive Devices: [Device selection, sizing, training plan]
• Other Comorbidities: [Mood, cognition, dizziness/vertigo workup, incontinence, osteoporosis; escalation/referral plan for unexplained falls] (Include only as relevant)

Education Provided

• [Topics covered: getting up slowly, night lighting, bathroom safety, safe transfers, how to get up after a fall, when to call 911]
• [Who received education: patient / caregiver / both]
• [Method: verbal / written handout / video; teach-back: completed / not completed]

Follow-Up

• [Follow-up interval] (Typically 30–90 days)
• [What will be reassessed: fall count, functional measures, orthostatics, medication changes, adherence]
• [Instructions if fall occurs before follow-up]

Safety Net

Red flags requiring urgent evaluation reviewed with patient/caregiver:

• Head injury warning signs
• New neurologic deficits
• Chest pain or syncope
• Severe dizziness or inability to bear weight
• Anticoagulant-related bleeding concerns

[Instructions provided and understood; teach-back if performed]