Post-Fall Nursing Assessment Form
Complete this form to document a comprehensive assessment following a patient fall.
Date and Time of Fall
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Fall
*
Please Select
Patient Room
Bathroom
Hallway
Nursing Station
Other
Circumstances of Fall
*
Slipped
Tripped
Lost Balance
Attempting Transfer
Unknown
Other
Immediate Post-Fall Condition
*
Alert and Oriented
Confused
Unresponsive
Drowsy
Other
Injury Indicators
*
No Apparent Injury
Bruising
Laceration
Swelling
Pain on Movement
Other
Pain Level (0 = No Pain, 10 = Worst Pain)
*
0
0
1
2
3
4
5
6
7
8
9
10
10
0 is 0, 10 is 10
Neuro/Mental Status Assessment
*
Rows
Normal
Abnormal
Not Assessed
Pupil Reaction
1
2
3
Speech
4
5
6
Motor Response
7
8
9
Level of Consciousness
10
11
12
Mobility and Assistive Device Status
*
Ambulates Independently
Requires Assistance
Uses Assistive Device
Bedbound
Other
Nurse Actions Taken
*
Vital Signs Monitored
Physician Notified
Family Notified
Incident Report Filed
Patient Repositioned
Other
Follow-up Notes / Additional Observations
Submit Assessment
Should be Empty: