Date:
Patient:
MRN:
Clinician: (Primary Care Physician, Geriatrician)
Reason for Visit:
Evaluation after a fall
Assessment of fall risk
Development of a fall prevention plan
History of Present Illness:
Briefly describe the details of the fall:
Date and time of the fall
Location of the fall (home, outside)
Circumstances surrounding the fall (witnessed vs. unwitnessed, any activities leading up to the fall)
Presence of any injuries sustained (with details on location and severity)
Past Medical History:
Include any relevant past medical conditions that may increase fall risk:
Gait and balance impairments (neurological conditions, musculoskeletal disorders)
Visual impairments (cataracts, glaucoma)
Cognitive decline (dementia)
Medication use (psychotropic medications, medications that cause dizziness or hypotension)
Previous falls
Social History:
Living situation (alone, with family)
Home environment assessment (presence of tripping hazards, adequate lighting)
Assistive device use (cane, walker)
Physical Exam:
Vital Signs: Temperature, pulse, blood pressure (orthostatic hypotension check may be relevant)
General: Mobility and gait assessment, balance testing (e.g., Romberg test)
Musculoskeletal: Joint range of motion, muscle strength
Neurologic: Mental status, reflexes, sensory examination (visual and proprioceptive)
Labs:
Consider mentioning any labs performed to rule out other causes of dizziness or syncope (if applicable).
Electrolytes and thyroid function tests may be checked in specific situations.
Imaging:
Imaging studies are not routinely performed for falls themselves, but may be obtained to evaluate potential causes of gait or balance problems (e.g., X-ray for suspected fracture).
Assessment:
Summarize the potential contributing factors to the fall based on history and physical exam findings.
Assess the patient’s overall fall risk using a validated fall risk assessment tool (e.g., STUG score, Downton Fall Risk Index).
Plan:
Outline a comprehensive fall prevention plan that addresses the identified risk factors:
Environmental modifications:
Home safety assessment and modifications (remove tripping hazards, improve lighting, grab bars in bathroom)
Medication review:
Discuss potential medication adjustments with the patient’s doctor to minimize dizziness or side effects that could increase fall risk.
Assistive devices:
Consider recommending a cane, walker, or other assistive device to improve mobility and gait.
Physical therapy:
Referral to physical therapy for gait training, balance exercises, and strengthening exercises.
Vision assessment and correction:
Encourage regular eye exams and address any vision problems that may contribute to falls.
Education:
Educate the patient and caregivers about fall prevention strategies and warning signs of potential falls.
Prognosis:
Briefly discuss the prognosis. Falls are a major health concern for the elderly, but implementing a fall prevention plan can significantly reduce the risk of future falls and associated injuries.
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the fall risk and their willingness to participate in fall prevention strategies.
Consider mentioning the need for follow-up visits to monitor progress and adjust the fall prevention plan as needed.
Disclaimer: This is a template and should be adapted to the specific needs of each patient.