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Humpty Dumpty Falls Scale (302003-DT)

Humpty Dumpty Falls Scale (302003-DT) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Patient Name

DOB:

MR #

Index to Home Health\Encounter
UWH302003-DT (Rev. 12/01/17) HUMPTY DUMPTY FALLS SCALE

UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
HUMPTY DUMPTY FALLS SCALE










Clinician Signature: _________________________________ Date: __________ Time: __________ Pager #: __________
Parameter Criteria Score (circle)
Age Less than 3 years old 4
3 to less than 7 years old 3
7 to less than 13 years old 2
13 years and above 1
Gender Male or Female under 3 years old 3
Male over 3 years old 2
Female over 3 years old 1
Diagnosis Neurological Diagnosis 4
Alterations in Oxygenation
(Respiratory Diagnosis,
Dehydration, Anemia, Anorexia,
Syncope/Dizziness, etc.)
3
Psych/Behavioral Disorders 2
Other Diagnosis 1
Cognitive
Impairments
Not Aware of Limitations 3
Forgets Limitations 2
Oriented to own ability 1
Environmental
Factors
History of Falls 3
Patient uses assistive devices 2
None 1
Medication
Usage
Multiple usage of:
Sedatives
Hypnotics
Barbiturates
Phenothiazines
Antidepressants
Laxatives/Diuretics
Narcotic
3
One of the meds listed above 2
Other Medications/None 1

TOTAL

Date: ___________________________

Age: ___________________________
Patient Falls Safety Protocol

Low Risk Standard Protocol (score 6-11)
ξ Orientation to room
ξ Environment clear of unused equipment,
furniture’s in place, clear of hazards
ξ Patient and family education available to
parents and patient

High Risk Standard Protocol (score 12
and above)
ξ Identify patient with a “humpty dumpty
sticker” on the patient, and in patient
chart
ξ Educate patient/parents of falls protocol
precautions
ξ Accompany patient with ambulation
At risk for falls if score is 12 or Above
Minimum Score 6
Maximum Score 19