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Comprehensive Assessment

doctor and patientThere are many sources of fall risk (PDF) and they can vary by individual. Performing a comprehensive assessment allows health care providers to measure the range of factors associated with falling. A Comprehensive Assessment can be performed over several visits and be divided among key staff. Fall risk assessments and prevention planning is eligible for reimbursement under the Medicare Annual Wellness Visit.

Based on initial screening, perform a comprehensive assessment on patients who:
  • Have difficulty with gait and balance, either self-reported or as determined by the Timed Get Up and Go (TUG) Test; or
  • Have had 2 or more falls in the last year.

 

A Comprehensive Assessment should include:

Relevant medical history
  • History of falls (frequency, symptoms, circumstances)


  • History of relevant conditions (previous injury, arthritis, chronic pain, osteoporosis, diabetes, cardiovascular conditions, incontinence, orthostasis, vestibular dysfunction, Parkinson’s disease, stroke)
Medication review
  • Medications known to increase risk, use of 4 or more medications
  • Over and behind the counter medicines, supplements, herbals
Physical exam
Cognitive and depression assessments Functional assessment
  • Screening questionnaire: Activities of daily living and related fear of falling using the Falls Efficacy Scale International (FES-I)
  • Use of assistive devices as appropriate
Discuss environmental hazards
  • Home assessment: CDC Check for Safety
  • Refer to Occupational Therapist if necessary

The Comprehensive Assessment will determine the most appropriate interventions to reduce the risk of falls.

 

Resources:

 

Last Updated: February 9, 2012