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 with 1 person assist||X||X||X|
|Safe with 2 person assist|
|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 originally created February 2010