Form

Outpatient falls risk screening record - JCI IPSG.6.1, ambulatory care (international)

Record outpatient falls risk screening, including history, risk factors, assessed risk level, implemented precautions, and patient education, for ambulatory care settings.

Fill it in online - free, no account needed. 32 questions.

What it is for

This template provides a structured record for outpatient falls risk screening in ambulatory care settings.

The full question list

1. Patient and Visit Details

  1. Date and time of screening *
  2. Patient's full name *
  3. Patient's unique identification number *
  4. Clinic or department where screening occurred *
  5. Reason for outpatient visit *

2. Falls History and Risk Factors

  1. Patient reports a history of falls within the last 12 months *
  2. Patient reports problems with mobility *
  3. Patient reports problems with balance *
  4. Patient is currently taking medications known to cause dizziness *
  5. Patient is currently taking medications known to cause sedation (e.g., opioids, benzodiazepines) *
  6. Patient received sedation during this outpatient visit *
  7. Patient requires assistance with ambulation (e.g., cane, walker, human assistance) *
  8. Patient reports impaired vision that affects mobility *
  9. Patient reports impaired hearing that affects mobility *

3. Risk Assessment and Level

  1. Based on screening, what is the patient's falls risk level? *
  2. Brief justification for the assigned risk level *

4. Precautions and Interventions

  1. Patient was offered an escort for ambulation within the facility *
  2. Patient was provided an escort for ambulation within the facility *
  3. Patient was offered a wheelchair for transport within the facility *
  4. Patient was provided a wheelchair for transport within the facility *
  5. Patient was advised on how to use a call bell *
  6. Patient was advised on how to request assistance if needed *
  7. Patient received verbal advice on safe ambulation practices (e.g., slow movements, using handrails) *
  8. Patient's discharge plan includes an accompanied discharge by a responsible adult *
  9. Other specific precautions or interventions implemented (if any)

5. Patient Education and Understanding

  1. Patient or accompanying family member verbally confirms understanding of falls risk factors discussed *
  2. Patient or accompanying family member demonstrates understanding of falls risk factors discussed (e.g., by rephrasing) *
  3. Patient or accompanying family member verbally confirms understanding of implemented precautions *
  4. Patient or accompanying family member demonstrates understanding of implemented precautions (e.g., by describing how to use a wheelchair) *

6. Clinician Sign-off

  1. Name of clinician completing this record *
  2. Clinician's professional title/designation *
  3. Clinician's signature *

References

How the score works

The score is the share of scored questions that pass. N/A is left out of the score; text, dates and signatures are recorded but not scored. A completed template is a record of what you checked; it is not an inspection by a regulator or an accreditation body.

Questions

Who should complete this screening record?

A qualified clinician responsible for patient assessment in an outpatient or ambulatory care setting should complete this record.

When should this record be completed?

This record should be completed during an outpatient visit when a falls risk screening is performed, particularly for patients identified with potential risk factors.