Home Safety Assessment & Fall Prevention Plan

Date/Time: [Encounter date and time]

Location: [in-home / facility / other]

Clinician: [Name and credentials]

Reason for Assessment: [Reason for home safety assessment]

Participants Present: [Participants present, roles, and relationships]

(Label key findings as observed, patient/caregiver-reported, or chart-derived when the distinction affects accuracy. Do not document that hazards were fixed or equipment installed unless verified during the encounter. If information is missing for a safety-relevant field, document the reason. Omit sections with no relevant information, except for Immediate Safety Concerns which should be included only when urgent hazards are identified.)

Immediate Safety Concerns

(Include this section only when urgent hazards are identified. Use precise language distinguishing recommended/demonstrated from completed/installed.)

• Urgent hazard(s): [Description of time-critical hazard(s) with location and mechanism] [observed / patient-reported]
• Mitigations completed today: [Actions verified as completed during the encounter and by whom]
• Actions recommended (not yet completed): [Specific recommendations with rationale and timeline]
• Escalations/communications: [Who was contacted, what was communicated, and recommended disposition]

Patient Goals & Context

[Brief narrative (2–4 sentences) summarizing patient-stated goals (use direct quotes when useful), priority activities to protect, living arrangement, indoor footwear habits, and relevant day/night routines affecting safety]

Fall History & Contributing Factors

• Falls and near-falls (past 12 months): [Number, timing, locations, activities, and injuries] [patient-reported / chart-derived]
• Symptoms impacting safety: [Dizziness/orthostasis, urgency/incontinence, vision changes, neuropathy, weakness, cognitive changes] (Include only if relevant to environmental or device interventions.)
• Medication-related risks informing plan: [Targeted medications or combinations that shape environmental or device recommendations] (Do not list comprehensive medication regimen.)
• Other contributing factors: [Balance, endurance, pain, recent functional changes] (Include only if they influence home modifications or device needs.)

Assessment Approach

• Mode of assessment: [In-person walkthrough / caregiver-facilitated] (Include context such as footwear worn, device used, and surface conditions during functional screens.)
• Validated tool(s) used: [Name of home hazard tool and score if applicable] (If a required tool was not completed, document the reason.)
• Functional screens performed: [Screen name(s) and conditions (footwear, device, surface), with observed performance]
• Limitations affecting validity: [Areas not assessed, patient fatigue, declined access, environmental constraints]

Assistive Devices & Equipment

(For each device present or newly recommended, document the items below. Omit devices not present unless recommending a new device.)

• Device: [Device name]
  • Current use pattern: [When/where used; consistency] [patient-reported / observed]
  • Fit/ergonomics check: [Handle height vs wrist, elbow flexion, posture alignment]
  • Condition & safety: [Tips, brakes, wheels, stability, wear]
  • Technique observed: [Observed technique and safety cues]
  • Identified issues/risks: [Misfit, unsafe technique, malfunction]
  • Adjustments or training completed today: [What was adjusted or taught and verification of effect]
  • Recommendations: [Repair/replace, accessories, referral for further fitting]
• Footwear assessment (Include when relevant to fall risk.)
  • Typical indoor footwear: [Description and fit] [patient-reported / observed]
  • Risks identified: [Slipperiness, lack of support, wear]
  • Actions: [Education, replacement recommended, changes completed today]

Home Environment Assessment

[Brief overview of home layout: single-story vs multi-level, primary sleeping/bathing level, notable access features]

(Document findings by location. For areas with identified hazards, use the full substructure below. For hazard-free areas, a single line stating the area was assessed with no concerns is sufficient. Omit areas not routinely used by the patient.)

• Entry/Egress
  • Hazards: [Hazards identified or "none identified"] [observed / patient-reported]
  • Risk mechanism: [Trip / slip / transfer instability / poor visibility]
  • Protective features present: [Existing rails, lighting, surfaces]
  • Mitigation recommendation: [Specific action and rationale]
  • Responsible party & timeframe: [Who will do what by when]
  • Status: [completed / pending / declined / not feasible] (If declined or not feasible, document reason.)
• Hallways/Transitions
  • Hazards: [Clutter, cords, thresholds, lighting] [observed / patient-reported]
  • Risk mechanism: [Trip / slip / poor visibility]
  • Protective features present: [Night lights, secured rugs, handholds]
  • Mitigation recommendation: [Actionable steps]
  • Responsible party & timeframe: [Details]
  • Status: [completed / pending / declined / not feasible]
• Stairs (indoor and outdoor)
  • Hazards: [Rails, lighting, uneven steps, treads, landing clutter] [observed / patient-reported]
  • Risk mechanism: [Trip / slip / transfer instability / poor visibility]
  • Protective features present: [Handrails, contrast markings]
  • Mitigation recommendation: [Specific installation, repair, training]
  • Responsible party & timeframe: [Details]
  • Status: [completed / pending / declined / not feasible]
  • Access limitations: [If stairs not assessed, document reason]
• Living Areas
  • Hazards: [Furniture spacing, low seating, cords, rugs] [observed / patient-reported]
  • Risk mechanism: [Trip / slip / transfer instability / poor visibility]
  • Protective features present: [Stable seating, clear pathways]
  • Mitigation recommendation: [Actionable steps]
  • Responsible party & timeframe: [Details]
  • Status: [completed / pending / declined / not feasible]
• Kitchen
  • Hazards: [Flooring, reach zones, step-stools, spill risk] [observed / patient-reported]
  • Risk mechanism: [Trip / slip / overreach / balance loss]
  • Protective features present: [Non-slip mats, organization aids]
  • Mitigation recommendation: [Actionable steps]
  • Responsible party & timeframe: [Details]
  • Status: [completed / pending / declined / not feasible]
• Bedroom and Night Pathway
  • Hazards: [Bed height, pathway clutter, lighting to bathroom] [observed / patient-reported]
  • Risk mechanism: [Trip / poor visibility / transfer instability]
  • Protective features present: [Night lights, reachable call device]
  • Mitigation recommendation: [Actionable steps]
  • Responsible party & timeframe: [Details]
  • Status: [completed / pending / declined / not feasible]
• Bathroom(s)
  • Hazards: [Tub/shower access, grab bars, toilet height, floor traction] [observed / patient-reported]
  • Risk mechanism: [Slip / transfer instability / overreach]
  • Protective features present: [Shower chair, non-slip surfaces, grab bars]
  • Mitigation recommendation: [Actionable steps]
  • Responsible party & timeframe: [Details]
  • Status: [completed / pending / declined / not feasible]
• Other routinely used areas (Include only if applicable.)
  • Hazards: [Area-specific findings] [observed / patient-reported]
  • Risk mechanism: [Mechanism]
  • Protective features present: [Features]
  • Mitigation recommendation: [Actionable steps]
  • Responsible party & timeframe: [Details]
  • Status: [completed / pending / declined / not feasible]

Caregiver & Support Assessment

(Include when caregiver involvement is present or needed for plan feasibility. Omit if patient is fully independent with no identified support needs.)

• Primary caregiver(s): [Availability, willingness, ability to assist or supervise]
• Barriers to implementation: [Caregiver burden, physical limitations, inconsistent presence, patient refusal of assistance]
• Community supports/resources: [Home health, senior programs, landlord/maintenance, funding sources, and status of applications if relevant]

Summary of Key Risks

[Brief synthesis (3–5 sentences) linking patient factors to environmental triggers, ranking priority hazards by severity, and explaining why these matter now (recent falls, functional changes, high-risk activities)]

Fall Prevention Plan

(List prioritized, specific, and measurable actions. Clearly distinguish actions completed today versus recommendations versus referrals.)

• Target hazard/problem: [Description]
  • Action: [Remove / secure / install / adjust / train / refer]
  • Responsible party: [Person or role]
  • Timeline: [Date or timeframe]
  • Status: [completed today / recommendation / referral placed]
  • Acceptance: [accepted / declined / undecided] (If declined, document reason.)
  • Follow-up metric: [Specific, observable outcome to verify completion]

Education & Teach-Back

• Topics taught: [Hazard reduction, safe transfers, device technique, footwear, recovery after a fall, when to seek help]
• Materials provided: [Handouts, digital resources, demonstrations]
• Teach-back verification: [What patient/caregiver was asked to demonstrate or explain; what was done correctly; what required re-teaching]
• Barriers to learning and adaptations: [Hearing, cognition, language, health literacy barriers identified and strategies used to address them]
• If teach-back not performed: [Reason and alternative method of assessing understanding]

Referrals & Follow-Up

• Referrals placed or recommended: [OT/PT, vision, medication review, falls prevention program, home modification services]
• Communications completed: [PCP notification, home health coordination, content of communication]
• Follow-up plan: [Timeframe, who will follow up, what will be reassessed, and how completion will be verified]
• Safety-netting instructions: [What to do after a fall, if new symptoms develop, or if unable to ambulate safely]