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Patient screened for future fall risk; documentation of 2 or more falls in the past year or any fall with injury in the past year (GER)

CPT4 code

Name of the Procedure:

Fall Risk Screening: Documentation of Fall History


This screening involves evaluating a patient's risk of future falls by documenting any history of two or more falls within the past year or any fall that resulted in an injury in the past year.


The main purpose is to identify patients at higher risk of falling so that preventive measures can be taken. This helps to reduce the likelihood of future falls and associated injuries.


  • Patients who have reported two or more falls in the past year.
  • Patients who have experienced a fall causing injury in the past year.
  • Generally indicated for older adults or patients with conditions that affect balance and mobility.


  • No special preparation required.
  • Patients should be prepared to provide a detailed history of falls, including dates, circumstances, and any resulting injuries.
  • May involve reviewing prior medical records.

Procedure Description

  1. The healthcare provider will ask the patient about any falls they have experienced in the past year.
  2. Details such as the number of falls, circumstances surrounding the falls, and any injuries resulting from these falls will be documented.
  3. Based on the information gathered, the provider might perform additional assessments or recommend further testing to evaluate balance, strength, and mobility.


The screening typically takes about 10-20 minutes, although this can vary depending on the complexity of the patient's history.


The screening can be performed in various settings, such as a primary care office, hospital, outpatient clinic, or during a home visit by a healthcare provider.


  • Primary care physicians
  • Nurses
  • Physical therapists
  • Geriatric specialists

Risks and Complications

  • There are no direct risks associated with the screening itself.
  • The procedure involves discussing past falls, which may be uncomfortable or distressing for some patients.


  • Early identification of patients at high risk for falls
  • Ability to implement preventive strategies to reduce future fall risk
  • Potential to avoid fall-related injuries and complications


  • No recovery time is required as the procedure is non-invasive.
  • Follow-up may include recommendations for fall prevention strategies or referrals to specialists.


  • This screening is typically part of a comprehensive fall risk assessment. There are no direct alternatives, but additional tests, such as gait analysis, balance tests, and home safety evaluations, can complement the screening.

Patient Experience

  • The patient might feel relief at addressing a serious health concern and discussing fall prevention strategies.
  • No pain or physical discomfort is involved.
  • Patients may feel peace of mind knowing that steps are being taken to improve their safety and well-being.

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