Falls Report Form | Health Care Solutions for Seniors

Falls Report - Primewest Senior Health Complete (HMO SNP)/Minnesota Senior Care Plus (MSC+)

Member first name

Invalid character

Member last name

Invalid character

Member PMI #

PMI can only contain numbers

Date of fall

Did the member have more than one fall on this date?

Yes

Please select an option

If yes, please indicate how many falls occurred on this date

Where was the member residing at the time of the fall?

Please specify "other"

Invalid character

Did the fall result in an ER visit?

Yes

Please select an option

What was the date of ER visit?

Did the fall result in a hospital admission?

Yes

Please select an option

What was the date of hospital admission?

Did the fall result in a fracture?

Yes

Please select an option

Fall Date	Multiple Falls	Residing	ER Visit (Date)	Hospitalized (Date)	Fracture	Actions
No falls added.
{{report.fallDate\|date:"MM/dd/yyyy"}}	{{report.multipleFalls\| yesNoFilter}}	{{appCtrl.getResidingName(report.residingAtTimeOfFall)}} {{report.otherResidence}}	{{report.isEmergencyRoomVisit\| yesNoDateFilter: report.emergencyRoomVisitDate}}	{{report.isHospitalAdmit\| yesNoDateFilter: report.hospitalAdmitDate}}	{{report.isFracture\| yesNoFilter}}