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Falls plan of care documented (GER)

CPT4 code

Name of the Procedure:

Falls Plan of Care Documented (GER)


This procedure involves documenting a detailed plan of care designed to prevent falls in patients, particularly those who are elderly or have conditions that increase their fall risk. The plan includes personalized interventions and strategies to enhance patient safety.


The Falls Plan of Care is aimed at addressing the risk of falls in patients. The goals are to identify risk factors, implement preventive measures, and ultimately reduce the incidence of falls and fall-related injuries.


  • History of previous falls
  • Impaired mobility or balance
  • Use of medications that affect stability
  • Cognitive impairments
  • Age-related factors
  • Environmental hazards


  • Comprehensive fall risk assessment
  • Review of patient’s medical history and current medications
  • Environmental safety evaluation
  • Patient and caregiver education on fall prevention strategies

Procedure Description

  1. Conduct a thorough fall risk assessment using standardized tools.
  2. Assess the patient's environment for potential hazards.
  3. Develop a personalized plan that includes:
    • Strength and balance exercises
    • Medication review and adjustments if needed
    • Installation of assistive devices (e.g., handrails, grab bars)
    • Education on safe transferring techniques
    • Regular monitoring and reassessment
  4. Document the plan in the patient’s medical record for interdisciplinary access and review.


Typically, the assessment and establishment of a falls plan of care take 1-2 hours. Follow-up assessments and adjustments may be periodic.


The procedure is usually performed in a hospital, outpatient clinic, long-term care facility, or in the patient’s home.


  • Primary care physicians
  • Nurses
  • Physiotherapists
  • Occupational therapists
  • Pharmacists (for medication review)
  • Social workers (for home safety evaluations)

Risks and Complications

  • The primary risk is inadequate assessment leading to ineffective fall prevention.
  • No direct procedural risks, but failure to properly implement the plan can result in continued fall incidents.


  • Reduced risk of falls and fall-related injuries
  • Improved patient confidence and mobility
  • Enhanced overall quality of life and safety


  • Ongoing monitoring and reassessment to ensure the effectiveness of the plan
  • Continued patient and caregiver education
  • Periodic follow-up appointments to update the plan as needed


  • No formal plan (reactive intervention only if falls occur)
  • Generic or non-personalized fall prevention strategies
  • Benefits of a personalized plan include tailored interventions and higher efficacy.

Patient Experience

  • Patients will undergo assessments and participate in recommended exercises.
  • They may receive training on using assistive devices.
  • Pain management is generally not required, but comfort measures, such as home modifications, can be implemented to enhance safety.

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