Mobility Assessment:

Presenting illness:

Medical History:

Premorbid level of function: /Activity /Exercise Response /Mobility Aids

Walking Distance

Primary Diagnosis:

Medications:

Investigations:

Blood Work: Hgb RBC Blood Sugar ECG Fluid & Electrolytes

Risk Factors:

Lifestyle Conditions:

Physician orders specific on mobilization

Multisystem Review:

Cardiovascular

Neurological

Musculoskeletal

Communication:

Level of Cooperation:

Cognition:

Orientation:

Patient concerns to Mobilization & readiness

Consider the impact of the illness or medical procedures & medications

Bed mobility Assessment:

Observation:
Posture

External Device

Check DVT

Surgery (Specific precautions)

Gait

Examination:

Function Grading:

Independent Minimal Moderate Max N/A

Assistance Assistance Assistance

Pelvic Bridging

Moving side to side Rt Lt

Moving up & down Rt Lt

Rolling Rt Lt

Supine to Sit

Sit to Stand

Sitting Balance

Sitting with support / without support for 10 sec

Ankle, knee & Hip Movements

Upper Extremity Strength

Standing Balance

Standing with support / without support for 10 sec

Stepping

Walking (Keep chair readily available on other side)

1. Time Up & Go >/= 14 seconds indicates increase risk of falls

2.Performace-Oriented Mobility Assessment (POMA) – 19/28 or less indicates increased risk of
falls

3. Berg Balance Scale 45/56 or less indicates an increased risk for falls

4. 5 Time Sit to Stand test A score of 12 seconds or more indicates an increased risk for falls

5.Gait Speed (10 Meter Walk)