Get Wilson Sims Fall Risk Assessment Tool 2020-2025

The Wilson Sims Fall Risk Assessment Tool is an essential resource for evaluating fall risk in psychiatric inpatients. This guide provides clear instructions on how to accurately fill out the assessment tool online, ensuring a comprehensive understanding of each section.

Follow the steps to complete the assessment effectively.

1. Press the ‘Get Form’ button to access the Wilson Sims Fall Risk Assessment Tool and open it in an online editor.
2. Begin by entering the patient’s age, selecting the appropriate category: 0 for ages 18-59, 1 for ages 60-70, and 2 for ages 71 and above.
3. Choose the patient's gender by selecting 0 for male or 1 for female.
4. Assess the patient's mental status and select one of the following options: 0 for oriented and cooperative, 1 for oriented and uncooperative, or 2 for confused or intoxicated.
5. Evaluate the patient's physical status by selecting between 0 for healthy, 1 for generalized muscle weakness, 2 for dizziness or vertigo, or 3 for cachexia and wasting.
6. Determine the patient's elimination status by choosing 0 for independent and continent, 1 for catheter or ostomy, 2 for assistance needed, or 3 for incontinence.
7. Assess impairments, selecting 0 for none, 1 for uncorrected visual or hearing issues, 2 for limb amputations, or 3 for neurological paralysis.
8. Evaluate the patient's gait or balance and select the appropriate status: 0 for able to walk/stand unassisted, 1 for physically unable to walk/stand, 2 for walking with a cane, or 3 for unsteady walking or reliance on furniture.
9. Review the patient's history of falls in the past six months, selecting 0 for no history, 1 for near falls or fear of falling, 2 for 1-2 falls, or 3 for multiple falls.
10. Evaluate the patient's medication status for mood stabilizers, benzodiazepines, diuretics, narcotics, sedatives/hypnotics, and atypical antipsychotics, marking the appropriate choices based on the patient's current medication regimen.
11. If applicable, select the status for detox protocol, marking 0 for not on detox or 7 for on detox protocol.
12. After all entries are made, review the total score calculated by the tool, noting that a score of 0-6 indicates low risk, while a score of 7 or above indicates high risk.
13. Complete the fall risk comments section with any relevant observations or clinical judgments that could impact the assessment.
14. Once all fields have been completed and reviewed, save your changes, and choose to download, print, or share the assessment as needed.

Start filling out the Wilson Sims Fall Risk Assessment Tool online today for effective fall risk evaluation.