AGE

0-6 YEARS (4)

7-18 YEARS (2)
19-64 YEARS (1)
65-79 YEARS (2)
80 YEAR AND ABOVE (3)
FALL HISTORY
FALL WITHIN 3 MONTHS BEFORE ADMISSION (5)
FALL DURING THIS HOSPITALIZATION (11)
NO HISTORY OF FALL (0)
MOBILITY
VISUAL OR AUDITORY IMPAIRMENT AFFECTING (4)
MOBILITY
AMBULATES OR TRANSFERS WITH UNSTEADY GAIT AND (2)
ASSISTIVE ADVICE
AMBULATES OR TRANSFERS WITH ASSISTANCE OR (2)
ASSISTIVE DEVICE
AMBULATES WITHOUT ASSISTANCE (0)
ELIMINATION
URGENCY/NOCTURIA (2)
INCONTINENCE (5)
NORMAL PATTERN (0)
MENTAL STATUS CHANGES
AFFECTING AWARENESS OF ONE’S PHYSICAL (4)
LIMITATION
AFFECTING AWARENESS OF ONE’S ENVIRONMENT (2)
MEDICATION
TWO OR MORE PRESENT; OR SEDATED PROCEDURE (5)
WITHIN THE PAST 2 HOURS
PSYCHOTROPICS (ANTI-DEPRESSANTS, HYPNOTICS, (5)
ANTIPSYCHOTICS, SEDATIVES, BENZODIAZEPHINES, SOME
ANTI-EMETICS)
ANTICONVULSANT (5) DIURETICS/CATHATICS (5)
ANTI-HYPERTENSIVES (5)
ONE PRESENT (3)
NO MEDICATION (0)
PATIENT CORE EQUIPMENT
≥ PRESENT (2)
IV LINE (2) CHEST TUBE (2) INDWELLING (2)
CATHETER (2) OTHERS _______
PRESENT (1)
NO EQUIPMENT ATTACHED (0)
SCORE LEGEND:
0-5 POINTS – LOW RISK
6-10 POINTS – MODERATE RISK
ABOVE 10 POINTS – HIGH RISK