User Interface Name

Field Identifier

Definition

Data Value Format (code or other value)

Value Sets

Date of Assessment or Review

Assessment_Date

This is the date the actual risk assessment (or review) was carried out with the patient

8 digit numeric, CCYYMMDD
6 digit numeric: hh:mm:ss

Falls history
Circle how many falls in the last 12 months (each fall increases risk)

Falls_history

This is to indicate the number of falls the patient has had within the last 12 months

n1

0

1

3

4

5 +

Has the patient had an inpatient fall since last assessment?

Inpatient_fall

This is to indicate whether the patient has had an inpatient fall since the last assessment

n1

1 Yes

2 No

Does the patient have a fear of falling / anxiety?

Falls_fear_anxiety

This is to indicate whether the patient has a fear of falling / anxiety

n1

1 Yes

2 No

Multifactorial actions & interventions careplan details

Inpatient_fall_actions

This is for the assessor to detail any multifactorial actions

Free Text

Is the patient taking any of the following medication?

Anticoagulants

Anticoagulants

This is to indicate whether the patient is currently taking anticoagulants

n1

1 Yes

2 No

Sedatives, hypnotics, antipsychotics or diuretics

Sed_hypn_antipsych_diuretics

This is to indicate whether the patient is currently taking sedatives, hypnotics, antipsychotics or diuretics

n1

1 Yes

2 No

Medications that lower BP or cause dizziness

meds_lower_bp

This is to indicate whether the patient is currently on medication that lowers their blood pressure or causes dizziness

n1

1 Yes

2 No

Multifactorial actions & interventions careplan details

Meds_actions_careplan

This is to detail any multifactorial actions and interventions care plan that has been arranged regarding the patients medication

Free Text

Are there any of the following associated Risks:

Medically unwell e.g. scoring on NEWS

Medically_unwell

This is to indicate whether the patient is medically unwell e.g. scoring on NEWS

n1

1 Yes

2 No

Risk of seizures

Seizures

This is to indicate whether the patient is at risk of seizures

n1

1 Yes

2 No

Postural drop in BP

Postural_drop_in_bp

This is to indicate whether the patient has a postural drop in BP

n1

1 Yes

2 No

Multifactorial actions & interventions careplan details

associated_risks_actions

This is to detail any multifactorial actions and interventions care plan that has been arranged regarding any associated risks

Free Text

Any issues with Cognitive / Mental State e.g.  Agitated, restless, impulsive, disorientated or confused? THINK DELIRIUM and its cause

Cognitive_mental_state

This is to indicate whether the patient is agitated, restless, impulsive, disorientated, confused or has no issues with cognitive / mental state

n1

1 Yes

2 No

Multifactorial actions & interventions careplan details

Cognitive_actions_careplan

This is to detail any multifactorial actions and interventions care plan that has been arranged regarding the patient cognitive / mental state

Free Text

Any mobility issues e.g.
•  Needs help to stand, transfer and/or walk
•  Tries to walk unaided but unsafe, e.g. to toilet
•  Uses walking aids
•  Gait or balance problems
•  Seating? E.g. slipping out of chair

Mobility

This is to indicate whether the patient has any mobility issues

n1

1 Yes

2 No

Any foot health issues:

Does the patient have appropriate footwear?

Appropriate_footwear

This is to indicate whether the patient has appropriate footwear

n1

1 Yes

2 No

Foot health / pain?

foot_health_pain

This is to indicate whether the patient has any problems with foot health / pain

n1

1 Yes

2 No

Multifactorial actions & interventions careplan details

Foot_health_actions_careplan

This is to detail any multifactorial actions and interventions care plan that has been arranged regarding the patients foot health / pain

Free Text

Any Sensory Deficits:

Vision and / or hearing impairment?

Vision_hearing_impairment

This is to indicate whether the patient has any vision and / or hearing impairment

n1

1 Yes

2 No

Numbness, weakness or spatial perception problems?

Numbness_weakness_spatial_perception

This is to indicate whether the patient has any numbness, weakness or spatial perception problems

n1

1 Yes

2 No

Multifactorial actions & interventions careplan details

Sensory_deficits_actions_careplan

This is to detail any multifactorial actions and interventions care plan that has been arranged with regards to the patients sensory deficits

Free Text

Are there any issues with the following:
e.g. Equipment, nutrition and hydration, contince bundle, dementia, pain assessment, substance misuse, sleep deprivation and rest?

Other _issues

This is to indicate whether there are any issues with the following:
e.g. Equipment, nutrition and hydration, continence bundle, dementia, pain assessment, substance misuse?

n1

1 Yes

2 No

Multifactorial actions & interventions careplan details

Other_issues_actions_careplan

This is to detail any multifactorial actions and interventions care plan that has been arranged with regards to any other issues the patient may have 

Free Text

Does the Patient and Family identify other risks?

Patient_family_perspective

This is to detail whether the patients and family have identified any other risks

n1

1 Yes

2 No

Multifactorial actions & interventions careplan

Patient_family_perspective_actions_careplan

This is to detail any multifactorial actions and interventions care plan that has been arranged with regards to any risks identified by the patient or family

Free Text

Is there a history of fracture or oesteoperosis?

Fracture_history_osteoperosis

This is to indicate whether the patient has a history of fractures or osteoporosis

n1

1 Yes

2 No

Multifactorial actions & interventions careplan details

Fractuire_history_actions_careplan

This is to detail any multifactorial actions and interventions care plan that has been arranged with regards to there being a history of fracture or osteoporosis

Free Text

Based on this assessment are there any targeted interventions required?

Targeted_interventions

This is to indicate whether (based on this assessment) any targeted interventions are required

n1

1 Yes

2 No

Multifactorial actions & interventions careplan details

Targeted_interventions_actions_careplan

This is to detail any multifactorial actions and interventions care plan that has been arranged if targeted interventions are required

Free Text

Any other details?

Any_other_details

This is to include any other details relevant to the falls assessment

Free Text

After reviewing this risk assessment is the patient at risk of falls?

Risk_of_falls

This is to indicate that after reviewing the risk assessment the patient is or isn’t at risk of falls

n1

1 Yes

2 No