Schmid Fall Risk Assessment Tool Acute Care

To be completed on all patients upon admission, post-fall, and/or when

the patients status changes.
Score each area relating to patients current status. Weights are in parenthesis.
Total weight at bottom.
yyyy/mon/dd

Date of Initial Assessment:

Unit:

**Select only one indicator for each category.

Mobility

Score

Score

Score

Score

Score

Score

Score

Score

Score

Score

Score

Score

(0) Ambulates with no gait disturbance

(1) Ambulates or transfers with assistive devices
(1) Ambulates with unsteady gait and no assistance
(0) Unable to ambulate or transfer
Mentation
(0) Alert, oriented X 3
(1) Periodic confusion
(1) Confusion at all times
(0) Comatose / unresponsive
Elimination
(0) Independent in elimination
(1) Independent, with frequency or diarrhea
(1) Needs assistance with toileting
(1) Incontinence
Prior Fall History (within past 6 months)
(1) Yes Before admission (Home or previous inpatient care)
(2) Yes During this admission
(0) No
(0) Unknown
Current Medications
(1) A score of 1 is given if the patient is on 1 or more of the following
medications: Anti-convulsants / sedatives or psychotropics / hypnotics
(consider all medication side effects and role in fall risk.)
Total Score:
Completed By: (signature / designation)
Date: (yyyy/mon/dd)
Total Score
Score of 3 or more: Patient is at risk for falls and fall prevention interventions should be implemented see reverse side
103511 Alberta Health Services, (2009/06)

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Unit Standard Fall Prevention Protocol: Use for all Patients at Risk for Falls

Use appropriate orientation strategies with every interaction for as long as needed.

Use clear communication.

Assist patients who have hearing aids and/or glasses, to use them.

Do comfort rounds every 23 hours except at night if the patient is asleep (toileting needs,
hydration, position changes).

Teach the patient and family about fall risk and prevention strategies. Ask the patient and family
to help prevent falls.

Make sure the call bell, personal items, and walking aids are in easy reach.

Find out if the patient is able to use the call bell system.

Remind patients [who need assistance] to call for help when transferring, getting up, or toileting.

Help the patient to walk as soon as possible and as often as possible.

Check assistive devices are used correctly and fixed as needed.

Use incontinence products that dont affect the patients mobility.

Have the patient wear non-slip footwear for all transfers and ambulation.

Check there are no barriers to ambulation or transfers (e.g., clutter in the room and hallway)

Assign a room, type of bed, bed position, and height that allows safe transfer, ambulation, and
monitoring

Follow the Least Restraint policy

Use a bed alarm [when available] to alert staff when patients are trying to get out of bed on
their own

Fall Prevention Initiative, 2009

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