METRO HEALTH CARE SERVICES
SIDE-RAIL USE ASSESSMENT FORM
Client:________________________________ Record #:__________________
1. Is the client Non-Ambulatory? YES NO
2. Does the client’s level of consciousness fluctuate? YES NO
3. Does the client have alteration in safety awareness due to cognitive ? YES NO
4. Does the client have a history of falls? YES NO
5. Has the client displayed poor bed mobility or difficulty moving to a YES NO
sitting position on the side of the bed?
6. Does the client have difficulty with balance or poor trunk control? YES NO
7. Does the client have difficulty with postural hypotension? YES NO
8. Is the client on any meds which may require safety precautions? YES NO
9. Is the client currently using the side rail for positioning or support? YES NO
10. Has the client expressed a desire to have side rails raised while in bed for YES NO
safety and/or comfort?
11. Has the client requested that the side rails not be released while sleeping? YES NO
12. Is the client visually challenged? YES NO
INTERVENTIONS
Lower the bed to the floor.
Provide restorative care to enhance abilities to safely stand and walk.
Provide frequent staff monitoring at night.
Provide assisted toileting for the client at night.
Visual and verbal reminders to use the call bell.
Other: __
RECOMMENDATIONS: LEFT RIGHT BILATERAL NONE
Side Rails are indicated and serve as an enabler to promote independence.
The client has expressed a desire to have side rails raised while in bed.
Side rails do not appear to be indicated at this time.
Side rails are indicated due to the following medical conditions/symptoms:____________________
Other recommendations/comments:
