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Printed on 7/20/2026
For informational purposes only. This is not medical advice.
The Hendrich II Fall Risk Model is a hospital-focused fall-risk screening tool that combines key risk factors into a point-based score. It is commonly used in acute-care nursing workflows to identify patients who need intensified fall-prevention strategies.
Formula: Hendrich II total is the sum of weighted fall-risk factors (practical range 0-16).
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The 8 Hendrich II items: Confusion/disorientation/impulsivity (4 points — highest weight); Symptomatic depression (2 points); Altered elimination — urgency or incontinence (1 point); Dizziness or vertigo (1 point); Male sex (1 point); Any antiepileptic medications including gabapentin/pregabalin regardless of indication (2 points); Any benzodiazepine medications (1 point); Get Up and Go Test result — 0 for normal/mild, 1 for moderate, 2 for severely impaired (max 2 points). Score each item per its weighted value and sum for the total.
Sum all items for a total from 0 to 16. A score of 5 or higher is the high-risk threshold. A confused patient (4 points) is nearly at threshold from this item alone, reflecting the primacy of cognitive impairment as a fall predictor. Reassess after medication changes, post-operative day 1, and whenever cognitive or mobility status changes significantly.
Address each positive item: Confusion — delirium assessment (CAM/4AT), bed alarm, reorientation; Depression — mental health review, motivation-based assistance; Altered elimination — scheduled voiding q2h, bedside commode; Dizziness — orthostatic BP, vestibular evaluation, assistance with position changes; Antiepileptic/benzodiazepine medications — review for lower-burden alternatives; Impaired Get Up and Go — PT referral, gait aid, supervised ambulation. Document interventions addressing each specific positive item.
Inpatient nurses, admission nurses
Hendrich II is designed for nursing-administered admission fall-risk assessment across acute care settings. Its inclusion of the Get Up and Go functional component alongside cognitive, pharmacological, and physiological items makes it more comprehensive than purely questionnaire-based tools, improving care plan completeness and high-risk patient identification consistency.
Pharmacists, hospitalists, geriatric consult teams
Explicit inclusion of antiepileptic (2 pts) and benzodiazepine (1 pt) medication items makes Hendrich II particularly useful for identifying medication-related fall risk. A patient on both already scores 3 from medications alone, prompting review of necessity and consideration of lower-burden substitutions.
Post-operative nurses, surgical ward nurses
Post-operative patients frequently score high due to confusion from anesthesia, altered elimination from catheter removal, and dizziness from opioids and position changes. Early Hendrich II scoring identifies the highest-risk period and supports proactive prevention including monitored first ambulation and early physical therapy.
Cardiac nurses, medical-surgical nurses
Hendrich II was originally validated in cardiac and medical-surgical settings. The dizziness/vertigo item captures orthostatic hypotension — particularly prevalent in cardiac patients on antihypertensives — as a modifiable fall risk contributor warranting immediate clinical evaluation and medication review.
Patient safety committees, nurse managers
Hendrich II serves as a standardized outcome measure in falls quality improvement programs. Units implementing Hendrich II with structured prevention protocols and staff education have reported fall rate reductions of 25-50%. Aggregate scores and compliance rates provide reportable process metrics for safety committees.
With 4 points assigned, confusion/disorientation/impulsivity is weighted more heavily than any other item. A confused patient is nearly at high-risk threshold alone. Always evaluate whether confusion is new (possible delirium requiring medical investigation) versus chronic (established dementia) — the prevention approach differs significantly between these presentations.
The GUG component must be based on directly observed patient movement, not chart review or self-report. Score 0 for normal/mild (rises with one attempt, steady gait), 1 for moderate (multiple attempts, significant armrest use), 2 for severely impaired or unable. Patients who have not yet attempted ambulation must be observed before this item can be scored.
Gabapentin and pregabalin — commonly prescribed for neuropathic pain, fibromyalgia, and anxiety — score 2 points as antiepileptic medications regardless of indication. These are among the most commonly overlooked contributors to Hendrich II scores. Always review the complete medication list for all antiepileptic agents, not just seizure medications.
Adding an antiepileptic or benzodiazepine can immediately push a patient from low to high risk. A patient started on lorazepam for alcohol withdrawal gains 1 point; combined with developing withdrawal confusion (4 points), the score can jump from 2 to 7 within hours. Reassess within 4-8 hours after adding these medications.
The depression item requires proactive assessment — asking patients about depressive symptoms rather than relying on documented diagnoses. Many hospitalized older adults have clinically significant depression not formally diagnosed. Use the PHQ-2 as a brief screen when completing Hendrich II for patients who appear withdrawn or apathetic.
Urgency and frequency in the 24-48 hours following urinary catheter removal are often severe and represent the highest urge-related fall risk period. Implement scheduled voiding and ambulatory assistance protocols immediately upon catheter removal in all high-risk Hendrich II patients.
The male sex item reflects statistical observations of higher male inpatient fall rates, not a reason to reduce prevention for female patients. All patients require appropriate precautions. Female patients with positive confusion and altered elimination items are at high risk requiring equivalent or more intensive prevention measures.
Hendrich II has broad adoption in inpatient fall-prevention programs with published validation data.
Higher Hendrich II totals indicate greater inpatient fall-risk signal and support proactive prevention measures.
Use in acute-care and inpatient settings where rapid standardized fall-risk triage is needed.
Predictive performance can vary by unit/patient mix; local validation and workflow integration matter.
For related assessments, see STRATIFY, Morse Fall Scale and Tinetti POMA.
Disclaimer: This tool is for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about your health.
April 21, 2026 · trust-baseline
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