| RPT |
|Missouri Alliance for Home Care - 10 questions (MAHC-10)
| Gender: <.Patient_Gender.>
|
| MAHC-10 Total = <-MAHC-10 Total->
|
| A score of 4 or more is considered at risk for falling.
|
|Questions and Answers:
|
| 1. Age 65+
| <*Answer_9557*>
|
| 2. Diagnosis (3 or more co-existing)
| Includes only documented medical diagnoses
| <*Answer_9558*>
| 3. Prior history of falls within 3 months
| Any unintentional change in position resulting in
| coming to rest on the ground or at a lower level
| <*Answer_9559*>
| 4. Incontinence
| Inability to make it to the bathroom or commode
| in timely manner. Includes frequency, urgency, and/or
| Date Given: <.Date_Given.>
| nocturia.
| <*Answer_9560*>
| 5. Visual Impairment
| Includes but not limited to, macular degeneration,
| diabetic retinopathies, visual field loss, age related
| changes, decline in visual acuity, accommodation, glare
| tolerance, depth perception, and night vision or not
| wearing prescribed glasses or having the correct prescription.
| <*Answer_9561*>
| 6. Impaired functional mobility
| Clinician: <.Staff_Ordered_By.>
| May include patients who need help with IADLS or ADLS or
| have gait or transfer problems, arthritis, pain, fear of
| falling, foot problems, impaired sensation, impaired
| coordination or improper use of assistive devices.
| <*Answer_9562*>
| 7. Environmental hazards
| May include but not limited to, poor illumination,
| equipment tubing, inappropriate footwear, pets, hard to reach
| items, floor surfaces that are uneven or cluttered, or
| outdoor entry and exits.
| Location: <.Location.>
| <*Answer_9563*>
| 8. Poly Pharmacy (4 or more prescriptions - any type)
| All PRESCRIPTIONS including prescriptions for OTC meds. Drugs
| highly associated with fall risk include but not limited to,
| sedatives, anti-depressants, tranquilizers, narcotics,
| antihypertensives, cardiac meds, corticosteroids, anti-anxiety
| drugs, anticholinergic drugs, and hypoglycemic drugs.
| <*Answer_9564*>
| 9. Pain affecting level of function
| Pain often affects an individual's desire or ability to move
|
| or pain can be a factor in depression or compliance with safety | recommendations.
| <*Answer_9565*>
| 10. Cognitive impairment
| Could include patients with dementia, Alzheimer's or stroke
| patients or patients who are confused, use poor judgment,
| have decreased comprehension, impulsivity, memory deficits.
| Consider patients ability to adhere to the plan of care.
| <*Answer_9566*>
|
|Information contained in this note is based on a self-report assessment
| Veteran: <.Patient_Name_Last_First.>
|and is not sufficient to use alone for diagnostic purposes. Assessment
|results should be verified for accuracy and used in conjunction with
|other diagnostic activities.
| SSN: <.Patient_SSN.>
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|
