Falls/Mobility Problems: Screening Questions

New patient:In the past 12 months, have you:

OR

Established patient:Since your last visit here, have you:

Fallen 2 or more times

Fallen and hurt yourself or needed to see a doctor because of the fall

Been afraid that you would fall because of balance or walking problems

Any triggers potential intervention

OFFICE VISIT FORM: FALLS/MOBILITY PROBLEMS

Reason for Visit: Fall since last visit (or in last year, if new patient) Fear of falling, balance/trouble walking

History of Present Illness:

  1. If patient fell, date of last fall: ______5. Uses device for mobility:YES NO
  2. Circumstances of fall:YES NO Cane………………………………………..

Loss of consciousness…………………. Walker……………………………………....

Tripped/stumbled over something…….. Wheelchair…………………………………

Lightheadedness/dizziness…………. Other, specify: ______

Unable or needed assistance to get up

Pattern similar to previous falls…….. 6. Other conditions (e.g., Parkinson’s, CVA,

cardiac, neuropathy, severe OA), specify:

  1. Psychotropic or medications (specify): ______

Neuroleptics: ______

Benzodiazepines: ______7. Vision:

Antidepressants: ______Noticed recent vision change…………….

Other med changes ______Eye exam in past year…………………….

  1. 2 or more drinks alcohol each day……..8. Hearing: Impaired / Normal…

Examination:

  1. Lying:BP: _____/_____ Pulse: _____2. If NO eye exam in past year, Visual Acuity: OS: 20/_____

Standing: BP: _____/_____ Pulse: _____Corrected OD: 20/_____

OU: 20/_____

  1. Cognition:3-Item recall: Pass Fail If FAIL Cognitive status:
  1. Gait: Normal Abnormal

Abnormal: ‘Timed Get up and go test’ if:-Hesitant start-Heels do not clear floor or toes of other foot

-Broad-based gait-Extended arms

-Path deviates-Time >10 secs

  1. Balance: YESNOIf indicated:YESNO

Side-by-side, stable 10 sec….Single leg stance 10 secs………..

Semi-tandem, stable 10 sec ..Romberg’s Eyes closed, nudge ….

Full tandem, stable 10 sec….. stable

  1. Neuromuscular Strength: YESNOYES NO

Quad strength: Can rise from chair w/o using arms……… Rigidity (e.g., cogwheeling).

Bradykinesia……………..

If indicated, hip ROM and knee exam: Tremor……………………

Upper Extremity function: Normal Grip ……….Touch top of head and back………………..

Diagnosis/Treatment Plan:

Lab/Tests: Blood tests Urine A and C/S X-rays chest

EKG/ Holter monitoring CT/MRI X-rays Injury - Fracture site

Impression: Strength problem Hip/knee OA Other______

Balance problem Orthostatic hypotension Syncope

Gait disorder Parkinsonism Anxiety/depression

Visual Impairment Medication issue Vestibular disorder

Treatment:

Patient education handout: Referral for PT

“Falls” Assistive device: ______

“Home safety checklist” Referral for OT home safety inspection/modifications

Strength/balance exercises: Change in medication(s): ______

Upper body Lower body Referral for eye exam

Community resources Cardiology consult

Personal or Community exercise program Neurology consult

Other: ______

Provider’s Signature______Date of Visit______

Health Alliance/University of Cincinnati

Reynolds Geriatrics Training Center

Billing diagnoses to consider for Falls, Balance and Mobility problems

Diagnosis

/

ICD-9 codes

/

Remarks

Dizziness / 780.4
Syncope / 780.2
Pre-syncope / 780.2
Vertigo / 780.4 NOS; 386.11 positional, benign paroxysmal; 386.2 cerebral; 386.19 auditory / Multiple dx fall under vertigo. This is a sample of different codes.
Parkinson’s Disease / 332.0
Parkinsonism / 332.0
Gait disorder / 781.2 abnormality of gait
Disequilibrium disorder / 781.2
Ataxia / 781.3
Osteoarthritis / 715.9x / Specify site for 5th digit
Delirium / 780.09 Unspecified; 290.3 senile dementia w/ delirium
UTI / 599.0 site unspecified
Pneumonia / 486 unspecified organism
Dementia / 294.8 NOS; 331.0 (294.11) Alzheimer’s w/ behavioral disturbance / Dementia has multiple codes.
Peripheral neuropathy / 356.9 Unspecified
Anxiety / 300.00
Depression / 311 NOS
Muscle weakness / 728.87
Muscle atrophy / 728.2 Amyotrophia
Balance disorder / 781.2
Physical deconditioning / 728.2
Medication review / V58.69 long term current use of other meds (high risk)
Acute pain / 780.99 other general symptoms / Specifiy site of pain for more accurate coding.
Chronic pain / 780.99 other general symptoms / Specify site of pain for more accurate coding
Soft tissue injury / 959.9 injury, other & unsp. / Specify site for more accurate coding.
Musculosketal injury / Requires site
Fracture evaluation / Requires site
Head injury / 959.01
Hematoma / 924.9 unspecified site
Skin Bruise / 924.9 unspecified site
Skin abrasion / Requires site
Vestibular disorder / 386.03 active Meniere’s disease, vestibular
Meniere’s disease / 386.00 unspecified
TIA / 435.9
Cardiac arryhthmias / 427.9
Hypertension / 401.1 benign
Hypotension / 458.9
Seizure disorder / 780.39
Vaso-vagal syncope / 780.2
Cerebrovascular disease / 437.9 unspecified

April 2005

Community Resources and Websites – Falls

Adaptive Devices

Arthritis Foundation 271-4545

Home Safety Education

Council on Aging – Caregiver Falls Education Home Visit345-8619

Hamilton County Falls Task Force 946-7802

Home Safety Education Program (Extension Office for OSU) 946-8987

Sycamore Township Community Outreach Program 792-8565

Home Safety Modification

Handyman Connection 771-1122

Handyman Housecalls 825-3863

People Working Cooperatively 351-7921

Medical Emergency Response

Lifeline Medical Emergency Response 559-2827

Physical Therapy and Exercise Programs

Alliance Physical and Occupational Therapy

Blue Ash 791-5656Mason 459-0801

Kenwood/Montgomery794-9300Mt. Auburn 585-0545

University Sports Med.475-8675Western Hills451-9555

Drake Center PM&R Services 948-2500

ElderFitness 559-2827

Hamilton County Health District - Falls Task Force (FTF) 946-7811

Maple Knoll Village Physical Therapy 782-2571

National Rehabilitation Information Center 1-800-346-2742

Stepping Stones 831-4660

Supplies

Bernens Western Hills 471-7575

Care Medical Reading 821-7272

Med Mart 733-8100

Mullaney’s Kenwood 793-6898

Pleasant Ridge 731-1400

West Chester 779-9808

Telephone Reassurance/Friendly Visitors

Arthritis Support Group 527-5048 ext. 320 Chatline (at Cedar Village) 754-3100 ext. 508

Jewish Family Service 469-1188

Service with Love (Christ Hospital) 585-6472

Websites

Administration on Aging: http://www.aoa.dhhs.gov/

Aging Network Services:

American Academy of Family Physicians:

American Association of Retired Persons:

Center for Disease Control: www.cdc.gov/ncipc/duip/spotlite/falls.htm

Elderweb:

Hamilton County Falls Task Force – Fall Prevention:

Home Modification Resource Center:

National Council on Aging:

National Institute on Aging: www.nih.gov/nia

National Osteoporosis Foundation:

National Rehabilitation Information Center:

National Safety Council:

Senior Friendly:

U.S. Consumer Product Safety Commission: http://www.cpsc.gov/