Assessment Tool: Hendrich II Fall Risk Model

A validated 8-item inpatient fall risk screen developed by Ann Hendrich. Assess each domain based on current patient status, including performance on the Get Up and Go test. A total score of 5 or above indicates high fall risk and requires targeted prevention protocol implementation. Reassess with any change in condition or per institutional policy.

Hendrich II Fall Risk Model

An 8-item validated fall risk assessment for adult inpatients, developed by Ann Hendrich. Scores range from 0 to 16. A score of 5 or above indicates high fall risk and warrants targeted prevention interventions.

Risk thresholds

0–4

Low risk

≥ 5

High risk — implement fall prevention protocol

1. Confusion / Disorientation

Organic brain syndrome, dementia, delirium, loss of contact with reality

0 – No confusion or disorientation 1 – Confusion present

2. Symptomatic Depression

Diagnosed depression, antidepressant therapy, or expressed sadness

0 – No symptomatic depression 1 – Symptomatic depression present

3. Altered Elimination

Urinary or fecal incontinence; urgency or frequency

0 – No altered elimination 1 – Altered elimination present

4. Dizziness / Vertigo

Patient-reported or clinically observed

0 – No dizziness or vertigo 1 – Dizziness or vertigo present

5. Sex

0 – Male 1 – Female

6. Antiepileptic Medications

Any antiseizure drug currently prescribed

0 – Not taking antiepileptics 2 – Taking antiepileptics

7. Benzodiazepine / Hypnotic Medications

Any benzodiazepine, sleep aid, or sedative-hypnotic

0 – Not taking benzodiazepines / hypnotics 1 – Taking benzodiazepines / hypnotics

8. Get Up and Go (Rise from Chair) Test

Observe patient rise from a standard armchair, walk 10 feet, turn, return, and sit

0 – Able to rise in a single movement; no loss of balance 1 – Pushes up and is successful in one attempt 3 – Multiple attempts required but is successful 4 – Unable to rise without human assistance

Result

Hendrich II Score: 0/16

Risk level:

BSN Program Tracker — Built with Astro and DaisyUI