Name a Risk Factor: _____________ Use of siderails on patient bed Risk factors: Patient has a visual impairment Use safety belts in the OR Risk factors: Patient uses assistive devices (cane, walker, etc.) Use wheelchairs for unsteady patients Staff to be present when patient is in the bathroom (after anesthesia) Risk factors: Loose cords that patients can trip over Make sure pediatric beds have padded siderails Identify a Risk factors related Patient history of falls Risk factors: Patient on multiple medications Fall assessment completed by PAT Use Fall Risk wristbands for high risk patients Risk factors at home: Tripping on loose rugs Risk factors: Slick or wet floors Locate a Fall Risk in the Hospital: _____________ Grab bars are available in the bathrooms Have PT provide walker training for total knees Risk factors at home: Tripping over pets Make sure crutches are fit properly to patient Provide crutch training as needed Use gait belt as needed Patients should wear non- slip socks Make sure patients have their call lights within reach Name a Risk Factor: _____________ Use of siderails on patient bed Risk factors: Patient has a visual impairment Use safety belts in the OR Risk factors: Patient uses assistive devices (cane, walker, etc.) Use wheelchairs for unsteady patients Staff to be present when patient is in the bathroom (after anesthesia) Risk factors: Loose cords that patients can trip over Make sure pediatric beds have padded siderails Identify a Risk factors related Patient history of falls Risk factors: Patient on multiple medications Fall assessment completed by PAT Use Fall Risk wristbands for high risk patients Risk factors at home: Tripping on loose rugs Risk factors: Slick or wet floors Locate a Fall Risk in the Hospital: _____________ Grab bars are available in the bathrooms Have PT provide walker training for total knees Risk factors at home: Tripping over pets Make sure crutches are fit properly to patient Provide crutch training as needed Use gait belt as needed Patients should wear non- slip socks Make sure patients have their call lights within reach
(Print)
O-Name a Risk Factor:
_____________
O-Use of siderails on patient bed
G-Risk factors: Patient has a visual impairment
I-Use safety belts in the OR
N-Risk factors: Patient uses assistive devices (cane, walker, etc.)
G-Use wheelchairs for unsteady patients
B-Staff to be present when patient is in the bathroom (after anesthesia)
N-Risk factors: Loose cords that patients can trip over
B-Make sure pediatric beds have padded siderails
I-Identify a Risk factors related Patient history of falls
B-Risk factors: Patient on multiple medications
I-Fall assessment completed by PAT
B-Use Fall Risk wristbands for high risk patients
G-Risk factors at home: Tripping on loose rugs
B-Risk factors: Slick or wet floors
I-Locate a Fall Risk in the Hospital:
_____________
G-Grab bars are available in the bathrooms
O-Have PT provide walker training for total knees
O-Risk factors at home: Tripping over pets
G-Make sure crutches are fit properly to patient
N-Provide crutch training as needed
N-Use gait belt as needed
I-Patients should wear non-slip socks
O-Make sure patients have their call lights within reach
