History of falling i Score 25 if the patient has fallen during the current hospital admission or has a history of physiological falls within the last 3 months. No recent falls (0 pts) Fall during this admission or within past 3 months (25 pts)
Secondary diagnosis i Score 15 if the patient has more than one medical diagnosis documented in their current care record. Single active diagnosis (0 pts) Two or more active medical diagnoses (15 pts)
Ambulatory aid i Select the mobility aid the patient uses. Furniture-clutching carries the highest score because it signals impaired balance without a proper device. No aid, bed rest, or wheelchair (0 pts) Crutches, cane, or walker (15 pts) Holds furniture or walls while walking (30 pts)
Intravenous therapy / heparin lock i Score 20 if the patient has an active IV infusion or an IV access device (heparin lock, PICC, port). IV equipment tethers movement and raises fall risk. No IV equipment (0 pts) IV line or heparin/saline lock in place (20 pts)
Gait i Normal includes a person who is fully immobile (bed rest / wheelchair) as they pose no ambulatory risk. Weak gait: slight stoop, short steps, uses furniture lightly. Impaired gait: very short shuffling steps, difficulty rising from a chair, almost always needs assistance. Normal gait, or immobile / bed rest (0 pts) Weak gait - stooped but maintains balance (10 pts) Impaired gait - shuffling, difficulty rising, needs support (20 pts)
Mental status i Ask the patient to describe what they think they can do independently. Score 15 if they overestimate their abilities or if cognitive impairment causes them to forget their limitations - a key predictor of unexpected falls. Oriented to own physical ability (0 pts) Overestimates ability or forgets limitations (15 pts)