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Elopement risk assessment form

Elopement risk assessment template 2026

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The document is an Elopement Risk Assessment tool designed to evaluate the risk of residents, particularly those with dementia or confusion, wandering or leaving a care facility. It includes a series of yes/no questions that assess mobility, behavior patterns, and history of elopement. A scoring system indicates risk levels, with a score of 5 or greater suggesting the need for precautionary measures such as monitoring, security bracelets, and family involvement in care planning.

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Click ‘Get Form’ to open the elopement risk assessment template in the editor.
Begin by answering the initial questions regarding the resident's condition. For each question, select 'Yes' or 'No' based on your assessment.
For questions that require scoring, input the corresponding score in the designated fields. Ensure accuracy as this will determine the risk level.
Once all questions are answered, review the total score at the bottom of the form. If it is 5 or greater, note that the resident may be at risk.
Proceed to address elopement precautions on the Care Plan section. Fill in details such as monitoring routines and security measures as needed.
Finally, ensure to notify family members and document any suggestions they provide in the appropriate fields before signing and dating the form.

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2017	4.5 Satisfied (56 Votes)

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