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Patient screened for future fall risk

HCPCS code

Name of the Procedure:

Fall Risk Screening, Fall Risk Assessment, Patient screened for future fall risk (M1069).

Summary

This procedure involves evaluating a patient's likelihood of experiencing a fall in the future. It uses a combination of questionnaires, physical assessments, and reviewing medical history to determine potential fall risks.

Purpose

The aim of this procedure is to identify patients who are at risk of falling so that preventive measures can be implemented. The goals are to reduce the incidence of falls, prevent fall-related injuries, and improve overall patient safety.

Indications

  • Patients with a history of falls
  • Elderly individuals, generally aged 65 and older
  • Patients with mobility issues or balance problems
  • Individuals with chronic conditions such as osteoporosis, arthritis, or neurological disorders
  • Those on medications that can affect balance or cognition

Preparation

  • Patients may need to bring a list of current medications.
  • Wear comfortable clothing and shoes suitable for walking.
  • No specific fasting or medication adjustments are usually required unless specified by the healthcare provider.

Procedure Description

  1. Medical History Review: The healthcare provider will review the patient's medical history, focusing on past falls, current medications, and existing health conditions.
  2. Questionnaire: The patient may be asked to complete a questionnaire assessing their risk factors, such as dizziness, vision problems, or difficulty walking.
  3. Physical Assessment: This includes tests such as:
    • Timed Up and Go (TUG): Patients are timed as they stand up from a chair, walk a short distance, turn around, walk back, and sit down.
    • Balance Tests: Various exercises to assess the patient's balance, including standing on one leg or walking heel-to-toe.
    • Gait Analysis: Observations of the patient's walking pattern.
  4. Risk Scoring: The results from the assessments are compiled to determine the overall risk of future falls.

Tools and equipment may include:

  • Stopwatch
  • Chairs
  • Balance Boards
  • Gait analysis mats or walkways

No anesthesia or sedation is required.

Duration

The complete screening process typically takes between 30 to 60 minutes.

Setting

The procedure is commonly performed in outpatient clinics, primary care offices, or specialized assessment centers.

Personnel

  • Primary Care Physician or Specialist (Geriatrician, Neurologist, etc.)
  • Nurses or Nurse Practitioners
  • Physical Therapists

Risks and Complications

  • Minimal risks are associated with the assessment itself.
  • Rarely, patients may experience minor dizziness or discomfort during physical assessments.

Benefits

  • Identification of fall risks allows for early intervention.
  • Development of personalized fall prevention strategies.
  • Improvement in safety and reduction in fall-related injuries.

Recovery

  • No specific recovery time is needed.
  • Patients may receive personalized recommendations, such as exercise plans or home modifications.
  • Follow-up appointments may be scheduled to monitor progress.

Alternatives

  • Functional Assessment by an Occupational Therapist: Focuses on daily living activities.
  • Home Safety Assessment: Identifies and mitigates fall hazards in the home.
  • Use of wearable technology to monitor falls and mobility issues.

Each alternative has its own advantages and might be less intrusive; however, they may not provide the comprehensive risk assessment achieved through clinical screening.

Patient Experience

During the procedure, patients might undergo various physical tests that can be mildly strenuous. However, healthcare providers will ensure comfort and safety throughout the assessment. Post-procedure, patients are generally able to resume normal activities immediately and will receive actionable advice to help mitigate any identified risks.

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