Schmid Score Assessment Tool 2g4b2v

Schmid Fall Risk Assessment Tool – Acute Care To be completed on all patients upon ission, post-fall, and/or when the patient’s status changes. Score each area relating to patient’s current status. Weights are in parenthesis. Total weight at bottom. yyyy/mon/dd

Date of Initial Assessment:

Unit:

**Select only one indicator for each category. Mobility

Score

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(0) Ambulates with no gait disturbance (1) Ambulates or transfers with assistive devices (1) Ambulates with unsteady gait and no assistance (0) Unable to ambulate or transfer Mentation (0) Alert, oriented X 3 (1) Periodic confusion (1) Confusion at all times (0) Comatose / unresponsive Elimination (0) Independent in elimination (1) Independent, with frequency or diarrhea (1) Needs assistance with toileting (1) Incontinence Prior Fall History (within past 6 months) (1) Yes – Before ission (Home or previous inpatient care) (2) Yes – During this ission (0) No (0) Unknown Current Medications (1) A score of 1 is given if the patient is on 1 or more of the following medications: Anti-convulsants / sedatives or psychotropics / hypnotics (consider all medication side effects and role in fall risk.) Total Score: Completed By: (signature / designation) Date: (yyyy/mon/dd) Total Score Score of 3 or more: Patient is at risk for falls and fall prevention interventions should be implemented – see reverse side 103511 © Alberta Health Services, (2009/06)

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Unit Standard Fall Prevention Protocol: Use for all Patients at Risk for Falls •

Use appropriate orientation strategies with every interaction for as long as needed.

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Use clear communication.

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Assist patients who have hearing aids and/or glasses, to use them.

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Do comfort rounds every 2–3 hours except at night if the patient is asleep (toileting needs, hydration, position changes).

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Teach the patient and family about fall risk and prevention strategies. Ask the patient and family to help prevent falls.

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Make sure the call bell, personal items, and walking aids are in easy reach.

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Find out if the patient is able to use the call bell system.

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Remind patients [who need assistance] to call for help when transferring, getting up, or toileting.

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Help the patient to walk as soon as possible and as often as possible.

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Check assistive devices are used correctly and fixed as needed.

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Use incontinence products that don’t affect the patient’s mobility.

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Have the patient wear non-slip footwear for all transfers and ambulation.

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Check there are no barriers to ambulation or transfers (e.g., clutter in the room and hallway)

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Assign a room, type of bed, bed position, and height that allows safe transfer, ambulation, and monitoring

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Follow the Least Restraint policy

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Use a bed alarm [when available] to alert staff when patients are trying to get out of bed on their own

Fall Prevention Initiative, 2009

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