Appendix C2: Mobility and Transfer Assessment Sample

The Falls Management Program Manual

Note: This form has been filled out with information for the sample case study patient, Mrs. P.

Resident: _____________Mrs._P_________________________   Room: ____401-A__________

The Mobility and Transfer Assessment is a 3-step process used to screen for problems related to balance, gait and transfer. During the assessment, the resident should use a cane, walker or wheelchair if she or he normally does so. The nurse should observe the resident's safety during ambulation using the Get Up and Go Test and during transfer in and out of bed, on and off the toilet and in and out of the lounge chair when one is used by the resident. The nurse should assess the resident's wheelchair for proper fit and positioning.

Step One: Put a check by the level of assistance needed by the resident in order to be safe during ambulation, bed transfer, toilet transfer and chair transfer.

Step Two: Put a check by those environmental adjustments needed for safety during ambulation or transfer.

Step Three: Complete the Wheelchair Screen. Put a check by each needed safety improvement.
For instructions to the Get Up and Go Test and Wheelchair Screen, go to the Falls Assessment Cue Sheet.

 Get Up and Go TestBed TransferToilet transferChair transfer
1. Level of Assistance
Safe independent    
Safe with 1 person assist XXX
Safe with 2 person assist    
PT referralX   
2. Environmental Adjustments
Adjust height of bed/toilet/ lounge chairMark _______ inches from floor for bed height.
Adjust handrail supportIn bathroom
Use assistive device? Walker use
Adjust assistive device 
OT/PT referralX Further evaluation necessary
3. Wheelchair Screen
Locate missing equipment 
Add labels to wheelchair and seating items 
Seat width needs adjustment 
Seat depth needs adjustment 
Seat height needs adjustment 
Armrest height needs adjustment 
Footrest(s) needs adjustment 
OT/PT Seating Assessment 
Signature: ____Susan_Brown_LPN___________________________ Date: ____4/3/04______________
Page last reviewed October 2014
Internet Citation: Appendix C2: Mobility and Transfer Assessment Sample: The Falls Management Program Manual. October 2014. Agency for Healthcare Research and Quality, Rockville, MD.