Falls Risk Assessment Documentation Audit

This project audits whether falls risk assessment and prevention documentation is completed reliably and meaningfully. It reviews identification of falls risk, falls history, mobility, gait and balance, cognition and delirium, vision, footwear and environment, continence, postural symptoms and lying-standing blood pressure, medication-related falls risk, bone health, individualised prevention planning, escalation and therapy or MDT referral, communication with the person and their carers, handover updates and post-fall review.

• Ward nursing teams, ward leaders and patient safety teams
• Acute medicine, geriatric medicine, frailty and orthogeriatric teams
• Physiotherapists, occupational therapists and rehabilitation teams
• Pharmacists and medicines optimisation teams
• Care home clinical leads and community teams where locally relevant
• QI leads, governance teams and educators

• Measure whether falls risk is identified and assessed according to local policy
• Assess coverage of the relevant multifactorial falls-risk factors
• Review whether prevention plans are individualised and interventions documented
• Identify variation in escalation, therapy referral, communication and post-fall review
• Generate governance-ready and ARCP-ready evidence

• Anonymous case identifier
• Inclusion / eligibility decision
• Anonymised biodata (age band, recorded sex/gender, care setting, assessment context)
• Clinical area / location and optional specialty / service
• Fourteen falls risk assessment documentation criteria (met / not met / not applicable)
• Free-text learning points and any project custom fields

• Live dashboard
• Audit report (Word)
• Executive summary (Word)
• Excel workbook
• PowerPoint presentation
• Conference poster
• ARCP evidence summary

This ready-built project is developed using the guidance, standards and authoritative sources listed below, so you can see what is being measured and why. Lazomis QI does not publish or own this guidance, and inclusion here does not imply endorsement or approval by any of these organisations.

• NICE

  NG249: Falls: assessment and prevention in older people and in people 50 and over at higher risk(opens the original source in a new tab)

  National guidance on identifying falls risk and delivering multifactorial assessment and intervention.

• NICE

  QS86: Falls in older people(opens the original source in a new tab)

  National quality statements covering falls risk identification, multifactorial assessment and prevention.

• Royal College of Physicians

  National Audit of Inpatient Falls (NAIF)(opens the original source in a new tab)

  National inpatient falls prevention and post-fall care standards, including FallSafe and CareFall resources where locally used.

• NICE

  CG103: Delirium: prevention, diagnosis and management in hospital and long-term care(opens the original source in a new tab)

  Relevant where delirium or cognitive impairment forms part of the local falls-risk assessment pathway.

• NICE

  NG5: Medicines optimisation(opens the original source in a new tab)

  Relevant where medicines review forms part of the local falls-risk assessment and prevention pathway.

• Designed to use anonymised or pseudonymised audit identifiers.
• This tool supports, but does not replace, clinical judgement.
• Local policy, formulary and specialist advice should be followed.
• Organisations remain responsible for local governance arrangements.
• This tool supports, but does not replace, clinical judgement. Follow local falls policy, multidisciplinary assessment and specialist advice.
• Risk-score thresholds, timing expectations and required interventions remain locally configurable and are not national standards.
• Use anonymous case identifiers only — never patient-identifiable information.

Supporting guidance from the Lazomis QI Resource Library. Authoritative clinical standards referenced by this project remain separate.

• Clinical GovernanceLeveraging Incident Themes for Quality Improvement and Patient SafetyThis guide helps NHS teams identify and analyse recurring incident themes, transforming reported safety events into practical quality improvement opportunities to enhance patient safety and system reliability.
• Quality ImprovementAvoiding Common PDSA Pitfalls: A Guide for Effective QIThis guide addresses frequent errors in planning, doing, studying, and acting (PDSA) cycles, offering practical advice to enhance the effectiveness of your Quality Improvement initiatives within the NHS.
• Patient SafetyLearning from Near Misses: Enhancing Patient Safety in the NHSThis guide provides practical strategies for NHS clinicians and teams to proactively identify, report, and learn from near misses, helping to prevent adverse events and improve patient safety.
• Patient SafetyIntegrating Patient Safety and Quality Improvement: A Practical Guide for UK CliniciansThis guide explains the foundational principles of patient safety and quality improvement (QI) within the UK healthcare context, offering practical strategies for clinicians to enhance safety and improve care delivery.