Healthcare Risk Assessment Template

HEALTHCARE RISK ASSESSMENT

Patient Information

Patient Name:    Date of Birth:

Phone:    Email:

Insurance Information

Policy Number:    Group Number:

Medical History & Current Status

Risk Domains — Assessment and Findings

For each domain, check applicable findings and provide brief supporting detail where indicated.

History of falls    Gait or balance impairment    Uses assistive device

Polypharmacy concern    High-risk medications (anticoagulants, sedatives)    Medication non-adherence

Pressure ulcer risk    Active wounds    Excessive moisture/skin breakdown

At risk of malnutrition    Signs of dehydration    Dysphagia or swallowing issues

Cognitive impairment / dementia    Suicidal ideation or self-harm risk    Behavioral disturbances/agitation

Social isolation/lack of support    Unsafe housing/environment    Financial barriers to care

Overall Risk Rating

Based on the above assessment, overall current risk level (select one):    Low    Moderate    High    Critical

Risk Mitigation Plan

Clinical Statements, Consent and Authorization

Purpose: This assessment documents identified clinical, functional and environmental risks that may affect the patient's safety or care. It is intended to inform the care plan and guide interventions. It does not constitute a guarantee of outcomes.

Confidentiality: Information recorded in this assessment will be maintained in the medical record and disclosed to members of the patient's care team as necessary for treatment, coordination of care, quality assurance, and as required by law.

Right to Refuse: The patient or authorized representative retains the right to refuse recommended interventions after being informed of risks and benefits. Refusal should be documented and alternative measures considered.

I authorize the release and exchange of information related to this risk assessment to other members of my health care team for the purpose of coordinating care and implementing the mitigation plan.

I acknowledge that I have been offered or provided information regarding the privacy practices applicable to my health information.

Assessment Completed By (Staff)

Patient / Representative Certification and Signature

I certify that, to the best of my knowledge, the information provided in this assessment is accurate. I have had the opportunity to ask questions regarding identified risks and planned interventions. By signing below I consent to the described information being placed in my medical record and shared with my care team as necessary to implement the risk mitigation plan.

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