The Baptist Health High Risk Falls Assessment (BHHRFA) can be used to identify an inpatient who is at high risk for falls. Such a patient may benefit from interventions to reduce that risk.
Patient selection: inpatient
Parameters:
(1) history of falls in the past 6 months
(2) age in years
(3) mental status
(4) frequent toileting
(5) urgency
(6) new mobility issue
(7) requires assistance (with transfers, use of walker, etc)
(8) medications (6 specified)
(9) nurse's clinical judgment (VAS scale from 0 to 10)
Parameter
Finding
Points
history of falls
no
0
yes
5
age in years
< 60 years
0
60 to 70 years
1
> 70 years
2
mental status
normal
0
confused
1
other
0
frequent toileting
no
0
yes
2
urgency
no
0
yes
2
new mobility issue
no
0
yes
2
requires assistance
no
0
yes
2
narcotics
no
0
yes
1
sedatives
no
0
yes
1
diuretics
no
0
yes
5
laxatives
no
0
yes
1
hypnotics
no
0
yes
1
insulin or oral hypoglycemic agent
no
0
yes
1
nurses's clinical judgment
from 0 to 10
Interpretation:
• minimum score: 0
• maximum score: 36
• A score >= 13 indicates high risk for falls.
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