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Falls risk assessment documented (GER)

CPT4 code

Name of the Procedure:

Falls Risk Assessment Documented (GER)


A Falls Risk Assessment is a systematic approach to evaluate an individual's risk of falling. This procedure involves evaluating various risk factors such as medical history, physical condition, and environmental hazards to prevent potential falls, especially in elderly patients.


The main purpose of a Falls Risk Assessment is to identify individuals at high risk of falls, particularly seniors, and to implement measures to reduce the likelihood of falls. The goals include maintaining patient safety, preventing injuries, and promoting long-term independence and mobility.


  • History of falls or near-falls
  • Balance or gait problems
  • Use of assistive devices (e.g., walkers)
  • Visual or auditory impairments
  • Cognitive impairment or dementia
  • Medication side effects that affect balance or alertness
  • Chronic conditions such as arthritis or diabetes


  • No specific dietary restrictions or fasting required.
  • It is important to provide a complete medical history, including details of any previous falls, current medications, and existing health conditions.

Procedure Description

  1. Initial Evaluation: The healthcare provider will review the patient's medical history, focusing on previous falls, medication use, and existing conditions.
  2. Physical Examination: Assessment of vital signs, mobility, balance, strength, and gait. Common tests may include the Timed Up and Go test (TUG) and the Berg Balance Scale.
  3. Environmental Assessment: Evaluation of the patient's living environment for hazards like loose rugs, poor lighting, or lack of handrails.
  4. Fall Risk Score Calculation: Using standardized tools and questionnaires, the provider will calculate a fall risk score.
  5. Recommendations: Based on the assessment, the healthcare provider develops a personalized fall prevention plan, which may include physical therapy, home modifications, medication adjustments, and education on safe practices.


The assessment typically takes 30 minutes to 1 hour.


It is usually performed in a hospital, outpatient clinic, or during a home visit by a healthcare provider.


  • Primary Care Physician or Geriatric Specialist
  • Nurse or Nurse Practitioner
  • Physical Therapist (if needed)
  • Occupational Therapist (if needed)

Risks and Complications

There are minimal risks associated with the assessment itself. However, the procedure aims to mitigate the significant risk of falls and their potential complications, such as fractures or head injuries.


  • Improved safety and reduced risk of falls
  • Enhanced quality of life and independence
  • Early identification and management of fall risk factors
  • Peace of mind for patients and caregivers


  • No recovery period is needed, as it is a non-invasive assessment.
  • Following the recommendations may involve physical therapy sessions, home modifications, and regular follow-up appointments to monitor progress.


  • There are no direct alternatives to a thorough falls risk assessment, but general health check-ups or specific balance/gait evaluations can provide some insights.
  • Pros: Comprehensive assessment provides detailed risk management plans.
  • Cons: May be seen as time-consuming, but the benefits outweigh the time invested.

Patient Experience

During the assessment, the patient may undergo various physical tests and answer detailed questions about their health and lifestyle. Some patients might feel self-conscious or anxious about demonstrating physical difficulties. Pain management is generally not required, but comfort measures like rest breaks and reassurance are provided to keep the patient at ease.

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