What is the best approach to document fall prevention in elderly patients with dementia or mobility issues?

How to Document Fall Prevention in Elderly Patients

Document fall prevention by systematically recording screening results using validated tools (Stay Independent questionnaire, three key questions, or Timed Up and Go test), documenting all P-SCHEME risk factors (pain, shoes, cognitive impairment, hypotension, eyesight, medications, environmental factors), and creating a specific intervention plan with measurable outcomes for each identified risk factor. 1, 2

Initial Screening Documentation

Document one or more of these validated screening approaches:

• Stay Independent Questionnaire: Record the total score out of 12 points, with scores ≥4 indicating increased fall risk requiring comprehensive evaluation 1
• Three Key Questions: Document yes/no responses to: (1) Have you fallen in the past year? (2) Do you feel unsteady when standing or walking? (3) Are you worried about falling? Any "yes" answer triggers broader assessment 1
• Timed Up and Go (TUG) Test: Record the exact time in seconds for the patient to rise from a chair, walk 3 meters, turn, return, and sit; times >12 seconds indicate increased fall risk 1
• 4-Stage Balance Test: Document ability to hold each position (side-by-side, semitandem, tandem, single-foot) for 10 seconds; inability to hold tandem stand <10 seconds indicates high risk 1

Comprehensive Risk Factor Assessment (P-SCHEME)

The Mayo Clinic recommends systematically documenting each component using the P-SCHEME mnemonic 1:

• Pain: Document presence, location, and severity of axial or lower extremity pain 1
• Shoes: Record footwear characteristics and appropriateness 1
• Cognitive impairment: Document Mini-Cog or Memory Impairment Screen results; abnormal results require further neurologic evaluation 2
• Hypotension: Record orthostatic blood pressure measurements (supine and standing at 1 and 3 minutes) 1, 2
• Eyesight: Document visual acuity and any visual impairments 1
• Medications: List all medications with specific attention to high-risk classes 1
• Environmental factors: Document home hazards identified 1

Medication Documentation Requirements

The American Geriatrics Society emphasizes that medication review is mandatory for all patients 2:

• Total medication count: Document if patient takes ≥4 medications (polypharmacy threshold) 2, 3
• High-risk medications: Specifically document use of psychotropic medications (OR 1.7), class 1a antiarrhythmics (OR 1.6), digoxin (OR 1.2), diuretics (OR 1.1), vasodilators, antipsychotics, sedative/hypnotics, benzodiazepines, and antidepressants 2, 3
• Medication modifications: Document any medications stopped, reduced, or changed as part of fall prevention 2

Physical Examination Findings

Document specific functional assessments:

• Gait observation: Record any abnormalities observed during ambulation 2
• Balance assessment: Document results of balance testing 1
• Muscle strength: Record proximal motor strength and presence of peripheral neuropathies 2
• Use of assistive devices: Document type and appropriateness of gait aids (RR 2.6 for fall risk) 3

Historical Risk Factors with Relative Risk

Document presence or absence of these ranked risk factors 3:

• History of falls (RR 3.0) 3
• Muscle weakness (RR 4.4) 3
• Gait deficit (RR 2.9) 3
• Balance deficit (RR 2.9) 3
• Visual deficit (RR 2.5) 3
• Arthritis (RR 2.4) 3
• Impaired activities of daily living (RR 2.3) 3
• Depression (RR 2.2) 3
• Cognitive impairment (RR 1.8) 3

Intervention Plan Documentation

Document specific, measurable interventions for each identified risk factor 2, 3:

• Exercise prescription: Specify type (balance training, gait training, strength training), frequency, and duration; exercise reduces fall risk by 23% (RR 0.77) 3, 4
• Vitamin D supplementation: Document dosing (≥800 IU daily recommended for deficiency or high-risk patients) 3, 4
• Physical therapy referral: Document if referred for gait training, assistive device evaluation, or balance program 1
• Home safety evaluation: Document specific environmental modifications recommended 3
• Medication changes: Document specific medications stopped or dose-reduced 2
• Treatment of underlying conditions: Document management of postural hypotension, cardiovascular disorders, vision impairment 2, 3

Disposition and Safety Assessment

Document safety evaluation before discharge 2:

• "Get Up and Go Test" results: Record pass/fail status 2
• Gait stability assessment: Document whether patient can ambulate safely 2
• Discharge safety determination: Document whether patient safety can be ensured at home or if admission is required 2

Follow-Up Documentation

Document the follow-up plan 3:

• Schedule for reassessment (annual minimum for average-risk, more frequent for high-risk) 3, 4
• Referrals made (physical therapy, occupational therapy, home safety assessment) 1, 3
• Timeline for expedited outpatient follow-up (1-2 weeks if discharged from emergency department) 3

Common Documentation Pitfalls to Avoid

• Failing to document time spent on ground: This is a critical severity indicator for patients presenting after a fall 2
• Incomplete head-to-toe examination documentation: Document complete examination even for seemingly isolated injuries to identify occult injuries 2
• Missing medication review: Especially critical for patients on ≥4 medications or any psychotropic drugs 2
• Vague intervention plans: Avoid documenting "patient educated on fall prevention" without specifying exact interventions and measurable goals 1, 2
• Discharging without documented safety assessment: Must document that patient passed functional testing before discharge 2