
Changing focus from repetitive screening for Falls Risk to a model
that supports Falls Prevention

Historically for each new issue addressed, we’ve added a new
section or Tab to HED – not sustainable and adds complexity to
documentation

As we work toward a Culture of Safety, we need a framework that
allows us to identify and address all safety risks efficiently and
document all education in a compliant, simpler fashion

Verbalize understanding of the changes in documentation and
workflow associated with new Falls/Safety HED build
Use a practice scenario to document Safety Assessment and Plan
including:





Determine the Morse Falls Risk Score
Identify safety risk factors and safety problems; Start Safety Priority Problem, if
warranted
Document Care Interventions, Patient/Family Teaching, and any Notifications &
Care Coordination actions
Document response to safety interventions & shift goals/outcomes for Safety
Priority Problems (if there is a Safety Priority Problem)
For your area, identify common Falls/Safety scenarios and how to
address them
Safety Documentation, including
assessment, interventions, teaching, and
notification, will result in a safer
environment for our patients and will
prevent or minimize injury.
This will improve patient care and clearly define
nursing’s contributions to patient care and the team.

Safety assessment on every patient, every shift. Also:
o Adults: Morse Falls screen
o Peds: Humpty Dumpty Falls
o
on admission & with change in status/condition (e.g. Transfer to different level of
care, change in mental status, etc.) . No longer required every shift.
o Streamlined documentation of Restraint Safety Care

Safety Problems (Injury Risk, Violence Risk, Substance Abuse, and
others) will be identified.
o If a safety problem will be a key driver of nursing care for that patient, also
initiate as a Priority Problem
o CIWA documentation will be available in HED for units that implement CIWA
protocol

Safety Interventions will be documented – things you:
o
o
o
o
Assess/Monitor/Evaluate/Observe
Care/Perform/Provide/Assist
Teach/Educate/Instruct/Supervise
Manage/Refer/Contact/Notify

Caregivers’ contact information (“Care Contacts”) – will be
documented in new Role/Communication section

Patient/Family Education & Engagement will be documented
in a way that captures required elements more efficiently

Plan of Care documentation
 Priority Problems – continue to create and evaluate goals
 Pathway, Nursing Summary, and Plan Priorities documentation in HED
 Continue to assign e-docs pathway

Admission History
 Continue to complete all sections (Contact Information will likely be
removed in future)
•
•
Admission
Falls Risk screen
Safety assessment as part of head-to-toe assessment; Identify problems
& Plan Interventions; Start Priority Problem if warranted
• Safety assessment; Identify problems & Plan Interventions
Beginning
of Shift
• Document expected Short Term Goals for Safety Priority Problems
• Start/End Safety Priority Problems if warranted
• Document Short Term Goal Status or outcome for Priority Problems
• Document Response to all Safety Interventions in Nursing Summary and
End of Shift
Plan Priorities
Condition/
Status
Change
• Falls Risk screen
• Repeat Safety Assessment & Revise Planned Interventions as appropriate
John Doe is an 85 year old male admitted for planned TURP for BPH.
Medical Conditions: COPD, Heart Disease, Hypertension, and migraine headaches.
Past Surgical Procedures: CABG (1987) Bilateral Knee Replacements (1997) shoulder
surgeries (2002 & 2005). He has a history of falls with injury (2 within the last 3 months),
resulting in rotator cuff tears and multiple rib fractures.
Medication History: 15 medications, some are anticonvulsants, Lortab for poorly controlled
headaches, 2 antihypertensive, and Lasix.
Family/Support: His wife, the primary caregiver, shares that a lot of medications make him
“dizzy” or “crazy”. She reports that he has stopped taking many medications because the side
effects contributed to falls.
On admission: Mr. Doe has no IV, is alert and oriented x3 , and verbalizes awareness that he
is very unsteady on his feet. He has Activity orders is to be OOB w/Assist and agrees to use
the call light any time he needs to get out of bed. His wife is concerned that he may try to go
to the bathroom without assistance because of urinary urgency and frequency associated with
his prostate issues. His daughter will be secondary caretaker and will come on the weekends
to relieve the wife.
Admission
• Falls Risk screen
• Safety assessment as part of head-to-toe assessment; Identify problems
& Plan Interventions; Start Priority Problem if warranted

Click on HED Train tab and select the Safety Falls/
Risk tab – this will be inserted in the assessment
tab for your unit on GO LIVE date

Locate and complete the Morse Falls Risk Section
Admission

• Falls Risk screen
• Safety assessment as part of head-to-toe assessment; Identify problems
& Plan Interventions; Start Priority Problem if warranted
Use the hover over box to see more information
on:
◦ Ambulation aid
◦ Gait
Admission
• Morse Falls Risk screen
• Safety assessment as part of head-to-toe assessment; Identify problems
& Plan Interventions; Start Priority Problem if warranted

Document the Safety Assessment on admission.

Consider creating a Safety Priority Problem, only if it is 2-3
of the main problems for patient on current shift.
◦ Restraints should always have an active Priority Problem and goal

Click on the Education tab and document contact
information for “care contacts”
• Safety assessment; Identify problems & Plan Interventions
Beginning of
Shift
• Document expected Short Term Goals for Safety Priority Problems
Complete Safety Assessment qshift and with
condition/status change
Complete Morse Falls Risk Screening on
admission and condition/status change only (not
qshift)
• Start/End Safety Priority Problems if warranted
• Document Short Term Goal Status or outcome for Priority Problems
• Document Response to all Safety Interventions in Nursing Summary and
End of Shift
Plan Priorities

Continue to start and end priority problems

Continue to evaluate goals at end of shift
NEW
Identify patient responses to Safety Interventions
in Nursing Summary and Plan Priorities
Question:
1. Do I document a
Falls Screen every
shift?
Answer:
1. No, only on admission
& changes in
condition/status
2. Do I still need to do
2. Yes, but only two fields
document restraints
every 2 hrs. ?
3. Will safety issues still 3. Sometimes but not all
Safety issues rise to that
be Priority Problems?
level.

New Safety/Fall Risk section will replace the old Falls
Risk section in Assessment/Interventions tab

New content will appear in Education tab

Restraints tab will be removed

Past data will be viewable for the Restraints and Fall
Risk sections of Assessments/Intervention Tab but will
not contain charting boxes.
Check with CAPS on GO LIVE dates for your area
Resources:
◦Provided by SSS:
 All resource materials will be accessible from Systems Support
Services Web Site by Sept. 25
 CAPS will partner with Unit-Based Resources to complete
education & will provide support
◦Provided by Unit:
Super-Users/ Educator
Need enough super-users for each shift Go Live week
Implementation
Support
 Super-user: 9a-5p and 9pm to 5am
 SSS: 9a-5pm and 9pm to 5am (Night Shift will
support multiple units concurrently; rounding
schedule to be posted)
Meet with CAPS person to formulate specific plan for our
unit
 Review the documents provided (posted on SSS website)
 Complete Unit-Specific Implementation Plan (including
recruiting Super-users) and use that Plan and Implementation
Checklist to track progress through implementation process
 Identify Super-users and best way to do training for your
unit

ASK QUESTIONS