Quick Guide for Scoring the Hendrich II Fall Risk Model®

HII Risk Factors

Assess. Understand. Establish.

The patient scoring guide includes eight proven, predictive fall risk factors on the Hendrich II Fall Risk Model® (HIIFRM). Each fall risk factor has an assigned risk weight based upon the study findings. If the person scores “yes” on a risk factor, the corresponding number of points are added to the person’s fall risk score in the box to the far right. If a person’s fall risk score totals 5 or more, the person is at high risk for falls, and requires fall prevention interventions to address their modifiable risk factors.

While a score of 5 or greater equals a statistically significant increased risk of falling, caregivers also must rely on clinical judgment and intuition when assessing fall risk. When a person scores only four points—or even fewer—they are still at some risk of falling, and you should use your best clinical judgment to address all fall risk factors as part of a holistic care plan.

Assess the risk factors

Use the HIIFRM tool to assess the 8 risk factors.

Review the person’s detailed history and physical (H&P). Ensure the assessment incorporates an evaluation of their social determinants of health.

Ask family, friends, caregivers, other providers, or the referral facility about their recent behavior and symptoms.

Observe their behavior and symptoms.

Reassess if patient condition changes or a minimum of once a shift.

Understand what matters most to the person

Find out and document what matters to the person.

Establish the historical baseline for diagnosis and comparison

Utilize the information collected when assessing the risk factors to determine the person’s historical baseline.

Compare the current assessment data with the historical baseline information.

If the current assessment and historical data are the same, ask the person’s family or caregiver what previously worked for them.

If the current assessment and historical data are different, determine approximate length of time symptoms and/or behaviors have changed from baseline.

Abstracted from Safe Mobility and Injurious Fall Reduction Clinical Resource Guide

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