Policy Manual sample

MDT Home Health Care Agency, Inc. 166 PATIENT RISK OF FALLS ASSESSMENT ___ POLICY: MDT Home Health Care Agency, Inc. staff takes appropriate actions to reduce the risk of patient harm due to falls. PROCEDURE: • At the time of the initial skilled assessment visit: • A basic home safety assessment is completed and documented in the patients medical record; • And the following items are assessed and documented in the record:  The patient’s functional limitations;  The patient’s current medications, both prescribed and over-the-counter, including herbal remedies, based on current knowledge for: ♦ Actions ♦ Drug-to-drug and drug-to-food interactions ♦ Dosage appropriateness ♦ Appropriateness of administration routes ♦ Medication effectiveness  Patient’s nutritional status  Patient’s pain level and pain management modalities • The above mentioned areas should be evaluated and documented in the patient record as to the degree of impact on the patient’s risk of harm from falls. • Recommend: The patient’s risk of harm from falls will be evaluated objectively on a scale of 1 to 10, similar to an objective pain scale. • The patient’s physician is to be notified of the patient’s potential for harm resulting from falls and a collaborative plan of action developed. • The patient/caregiver/significant other should be instructed about the potential risks and a plan documented in the record of the actions to be taken to reduce the risks. • A copy of the written plan is to remain in the patient’s home.