​Ambulatory surgical facilities can use this tool to screen patients for falls risk at three intervals: pre-admission, pre-operatively, and post-operatively. Complete all sections and implement falls prevention interventions in accordance with facility-specific protocols. Obtain information to complete the questions from the patient, the patient’s designee, a healthcare provider, a handoff form, or through observation.

Specific instructions for use are included in the assessment, which may be downloaded for electronic entry or printed for handwritten entry. The checklist is a PDF and requires Adobe Reader to view and/or use the electronic entry feature.