Appendix B6: Mobility and Transfer Assessment

The Falls Management Program Manual

Text Description of Form

Resident Name:________________________________  Unit/Room: _____________________

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, see the Falls Assessment Cue Sheet.

Get Up and Go TestBed TransferToilet transferChair transfer
1. Level of Assistance
Safe independent   
Safe with 1 person assist   
Safe with 2 person assist   
PT referral   
2. Environmental Adjustments
Adjust height of bed/toilet/ lounge chairMark _______ inches from floor for bed height.
Adjust handrail support 
Use assistive device 
Adjust assistive device 
OT/PT referral 
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: ______________________________________________ Date: ________________________

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Figure 12 Image

Current as of February 2010
Internet Citation: Appendix B6: Mobility and Transfer Assessment: The Falls Management Program Manual. February 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/fallspxmobility.html