The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities

Appendix C2: Mobility and Transfer Assessment Sample

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 Test Bed Transfer Toilet transfer Chair transfer
1. Level of Assistance
Safe independent        
Safe with 1 person assist   X X X
Safe with 2 person assist        
PT referral X      
2. Environmental Adjustments
Adjust height of bed/toilet/ lounge chair Mark _______ inches from floor for bed height.
Adjust handrail support In bathroom
Use assistive device ? Walker use
Adjust assistive device  
OT/PT referral X 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. October 2014. Agency for Healthcare Research and Quality, Rockville, MD.