Falls Referral

Purpose
This standardized referral tool is designed to ensure any older adult (65+) who experiences a fall or lift/assist event is consistently identified, documented, and referred for fall risk follow-up and prevention services. It creates a direct communication pathway to the Local Health Department Nurse (Fall Prevention Coordinator) regardless of entry point (EMS, hospital, urgent care, physical therapy, home health, or skilled nursing facility).

Question Title

1. Patient Information (Required.)

Question Title

2. Best Contact Method (Required.)

Phone call

Text

In-Person

Other (please specify)

Question Title

3. Living Situation: (Required.)

Alone

With family

Assisted Living

Skilled Nursing

Other (please specify)

Fall Event

Question Title

4. Event Type (Check all that apply)

Ground-level fall

Fall with injury

No injury fall

Near fall / loss of balance

EMS lift assist

Syncope-related fall

Mechanical fall (trip/slip)

Recurrent falls (2+ in 6 months)

No falls

Concerned about falling

Question Title

5. Location of Event

Home

Nursing facility

Assisted living

Public area

Hospital inpatient/outpatient

Physical therapy clinic

Other (please specify)

Question Title

6. Fall event location name & address

Question Title

7. Immediate Actions Taken (Check all that apply)

Wound care provided

EMS lift assistance provided

Referral to PCP advised

Transported to ED

Refused transport

Hospital admission

Discharged home

Question Title

8. Immediate Actions Taken Notes

Question Title

9. Clinical Outcome/Injury

No injury

Minor injury

Suspected fracture

Head injury

Loss of consciousness

Question Title

10. Clinical Outcome/Injury Notes

Question Title

11. Contributing Risk Factors (Check all identified)

Gait/balance impairment

Weakness/deconditioning

History of prior falls

Medication risk (sedatives, antihypertensives, polypharmacy)

Vision impairment

Footwear issues

Environmental hazard (clutter, rugs, poor lighting)

Dizziness/orthostatic hypotension

Cognitive impairment/confusion

Alcohol use

Assistive device not used or used incorrectly

Other (please specify)

Referring Organization/Agency

Question Title

12. Referring Organization or Agency's Detailed Information

Contact Person

Phone Number

Today's Date

Falls Referral

Question Title

* 1. Patient Information (Required.)

Question Title

* 2. Best Contact Method (Required.)

Question Title

* 3. Living Situation: (Required.)

Question Title

* 4. Event Type (Check all that apply)

Question Title

* 5. Location of Event

Question Title

* 6. Fall event location name & address

Question Title

* 7. Immediate Actions Taken (Check all that apply)

Question Title

* 8. Immediate Actions Taken Notes

Question Title

* 9. Clinical Outcome/Injury

Question Title

* 10. Clinical Outcome/Injury Notes

Question Title

* 11. Contributing Risk Factors (Check all identified)

Question Title

* 12. Referring Organization or Agency's Detailed Information

1. Patient Information (Required.)

2. Best Contact Method (Required.)

3. Living Situation: (Required.)

4. Event Type (Check all that apply)

5. Location of Event

6. Fall event location name & address

7. Immediate Actions Taken (Check all that apply)

8. Immediate Actions Taken Notes

9. Clinical Outcome/Injury

10. Clinical Outcome/Injury Notes

11. Contributing Risk Factors (Check all identified)

12. Referring Organization or Agency's Detailed Information