Inpatient Fall Prevention Assessment

Inpatient Fall Prevention Assessment — Form Fields

This healthcare template includes 14 fields. Nursing staff complete fall risk assessments for inpatient admissions to trigger appropriate prevention protocols. Free to customize and use on ZenBuild.

• Nurse Name (text, required)
• Patient Full Name (text, required)
• Date of Birth (text, required)
• Unit and Room Number (text, required)
• Assessment Date (text, required)
• History of Falls in Past 3 Months (dropdown selection, required) — options: Yes, No
• Secondary Diagnosis Present? (dropdown selection, required) — options: Yes, No
• Ambulatory Aid Used (dropdown selection, required) — options: None, Crutches/Cane/Walker, Furniture, Other
• IV or IV Access? (dropdown selection, required) — options: Yes, No
• Gait Assessment (dropdown selection, required) — options: Normal/Bedrest, Weak, Impaired
• Mental Status (dropdown selection, required) — options: Oriented to Own Ability, Forgets Limitations
• Total Morse Fall Score (number, required)
• Fall Risk Level (dropdown selection, required) — options: Low (0–24), Moderate (25–44), High (45+)
• Interventions implemented (long text, required)