Hendrich II Fall Risk Model: Clinical Guide

Overview

Estimates inpatient fall risk using eight weighted factors.

Clinical Significance

Use the result to support structured assessment, not as a standalone diagnosis or treatment decision.

When to Use

• Use when a structured assessment with this validated instrument is clinically appropriate.

How It Is Calculated

• Item values are summed and mapped to the published interpretation bands.

Interpretation

• Interpret the score with clinical findings, collateral information and current guidance.

Worked Example

Select a verified response for each item; MedicalC sums the assigned values and displays the interpretation band.

Limitations

• Screening and severity scales do not establish a diagnosis by themselves.
• Language, cognition, acute illness and setting can affect responses.

Clinical Pearls

• Document individual responses as well as the total score.
• Escalate immediately when an item identifies urgent risk, regardless of the total.

Common Mistakes

• Using incomplete responses.
• Ignoring item-specific red flags because the overall score is low.

References

1. Hendrich AL et al. Appl Nurs Res. 2003;16:9-21. — Primary or supporting reference for the implemented instrument.