Level 1
Unable to sit, reach, or participate safely
Think dependent mobility and in-bed care. Do not progress to standing or pivoting.
Welcome to This Module
BMAT gives nurses a quick, repeatable way to match mobility decisions to what the patient can safely do right now. The point is not to turn every nurse into a physical therapist. The point is to prevent the two common failures at the bedside: keeping patients in bed when they could safely move, and moving patients with the wrong assist or equipment.
This module is written for Thompson nurses who make or support patient mobility decisions. It is designed to take 20 to 30 minutes, including the final assessment. Complete the five content modules and pass the assessment with a score of 80% or higher to receive credit.
Viewing Tip
For the smoothest review experience, use a full-size browser window when possible. The module still works on smaller screens, but the practice tools, audio player, and transcript are easier to use with more room.
Recommended: Listen Mode
When you enter each content module, the audio guide opens beside the page. Press play to use the guided version with the transcript; the audio pauses at practice activities when needed. Use Read mode anytime you prefer to review the text only.
Learning Objectives
After completing this module, you will be able to:
- Explain why nurse-driven mobility assessment matters for patient outcomes and staff safety.
- Perform the BMAT sequence using a safety screen, stop points, and the four core maneuvers.
- Assign a practical mobility level and select an appropriate transfer or mobility plan.
- Apply BMAT reasoning across patient care situations that require judgment.
- Document, hand off, and escalate changes in mobility status using Thompson policy.
Module Map
| Step | Topic | Practice Focus |
|---|---|---|
| 1 | Why mobility matters | Immobility harm, fall risk, staff injury, and mobility as nursing care |
| 2 | The BMAT sequence | Safety screen, sit and shake, stretch and point, stand, step |
| 3 | From level to equipment | Safe patient handling, transfer choices, and what BMAT does not replace |
| 4 | Practice scenarios | Patient care situations that require judgment |
| 5 | Document and escalate | Handoff language, reassessment, PT/OT triggers, and Thompson documentation rules |
| 6 | Assessment | 12-question knowledge check, 80% passing score |
Evidence Base
This module is grounded in published BMAT validation work, the BMAT 2.0 update, intensive care unit early mobility guidelines and trials, inpatient immobility studies, safe patient handling guidance, obstetric fall-risk literature, Thompson policies CC.15.004.07 and CC.13.001.57, and Thompson's BMAT/SPH quick-reference materials.
Think First
Your patient has been in bed for most of the day. They are alert, asking to use the bathroom, and say, "I walked fine at home." No one has documented today's mobility level yet.
What is the safest nursing move?
AudioGuided teaching trackRecommended
Recommended for most learners: press play and let the transcript follow the page. The audio pauses at practice activities when needed; Read mode remains available if you prefer text only.
Transcript lines are timed from the generated recording and can be clicked to jump within the audio.
Module 1: Why Mobility Matters
Mobility Is Nursing Care
Mobility is not an "extra" task that happens only when the shift slows down. For hospitalized adults, time in bed is associated with functional decline, deconditioning, pressure injury risk, delirium risk, discharge delays, and loss of independence. For staff, poorly planned transfers create preventable injury risk.
BMAT helps the nurse answer a bedside question quickly: What can this patient safely do right now, and what support or equipment is needed?
1
Standard language for bedside mobility status
4
Core maneuvers used to progress the assessment
0
Manual hero lifts expected from staff
Any
New decline requires reassessment and escalation
Evidence Connection
BMAT was developed and validated as a nurse-friendly mobility assessment to connect patient functional ability with safe patient handling decisions. Thompson policy makes that connection local: patients must be assessed with the approved tool, transfer recommendations must be documented in the EMR, and BMAT is the referenced assessment tool for safe moving and handling.
Thompson Policy Snapshot
| Policy Point | What It Means At The Bedside |
|---|---|
| BMAT timing | Administer BMAT at least once per day and as needed when patient status changes. Patients in the intensive care unit also have physical ability determined with BMAT on admission or transfer to the intensive care unit and at least once per 12-hour shift. |
| Documentation | Document the safe lift/transfer recommendation in the EMR. Thompson's safe handling policy places BMAT documentation in Epic flowsheets, Vital Signs tab, under Mobility. |
| If movement is needed before assessment | Use the highest level of equipment to protect the patient and associates until a validated assessment performed by a licensed nurse is completed and documented. |
| When in doubt | Default to the safest BMAT level and transfer method. The Thompson RN Reference Tool specifically reminds staff to err on the side of caution. |
| Manual lifting limit | No individual should manually lift patients weighing more than 35 pounds without an appropriate assistive device or safe patient handling equipment. |
Why "Right Now" Matters
A patient's baseline matters, but it is not enough. A person who walks independently at home can be unsafe after anesthesia, opioids, sepsis, orthostasis, acute neurologic change, hypoxia, delirium, or a long ED wait. A patient who needed help yesterday may be ready to progress today.
BMAT is useful because it captures the current bedside reality. It gives the nurse a repeatable way to start low, progress only as tolerated, and stop when the next step is unsafe.
Quick Check
A patient was independent before admission but now gets dizzy sitting at the edge of the bed. Should baseline independence override the current finding?
No. Baseline independence is important history, but the current safety screen controls the immediate plan. Dizziness, orthostasis, new weakness, or inability to follow directions means stop, support the patient, reassess, and escalate as needed.
What BMAT Does And Does Not Do
| BMAT Helps With | BMAT Does Not Replace |
|---|---|
| Choosing safe assist level and equipment for routine bedside movement | A full PT/OT evaluation when there is new impairment, discharge planning need, or complex mobility issue |
| Standardizing mobility language across shifts and teams | Clinical judgment when vital signs, lines, sedation, or orders make mobility unsafe |
| Reducing guesswork before getting out of bed, transfers, toileting, and ambulation | Thompson's safe patient handling policy, fall prevention policy, or provider activity orders |
Bedside Takeaway
BMAT is a nursing decision tool for safe movement now. It should make mobility more likely when safe, and make unsafe transfers less likely when equipment or more help is needed.
Clinical Scenario
An older adult urgently needs to use the bathroom. They are alert, on 2 L nasal cannula, and had a fall at home before admission. They can follow directions, but no mobility level is documented yet.
What is the safest immediate plan?
AudioGuided teaching trackRecommended
Recommended for most learners: press play and let the transcript follow the page. The audio pauses at practice activities when needed; Read mode remains available if you prefer text only.
Transcript lines are timed from the generated recording and can be clicked to jump within the audio.
Module 2: The BMAT Sequence
Start With A Safety Screen
Before any mobility test, ask whether it is safe to proceed. BMAT is not a reason to ignore unstable vital signs, activity restrictions, new neurologic symptoms, severe pain, oversedation, unsafe lines or tubes, or a patient who cannot follow directions.
Stop Before Testing If Needed
Stop and reassess before BMAT if the patient has an order or condition that makes mobility unsafe. Examples include strict bedrest or non-weight-bearing orders, uncontrolled symptoms, new chest pain, severe dyspnea, syncope, unassessed neuro change, unstable hemodynamics, active hemorrhage, unstable fracture, neuromuscular blockade, inability to follow cues, or another restriction that requires provider clarification.
Thompson Cadence
For most areas, BMAT is administered at least once per day and as needed with a change in patient status. For patients in the intensive care unit, Thompson's A-F Bundle says physical ability is determined with BMAT upon admission or transfer to the intensive care unit and at least once per 12-hour shift.
This is why screening early matters: urgent toileting, imaging, and transfers happen fast, and it is much safer to already know the patient's mobility plan than to guess under pressure.
The Four Maneuvers
BMAT progresses from lower demand to higher demand. The patient should pass the current maneuver before moving to the next. The highest level is based on what the patient can safely complete today.
1
Sit and shake
Can the patient sit upright, maintain balance, and reach to shake your hand?
2
Stretch and point
Can the patient demonstrate leg strength and control while seated?
3
Stand
Can the patient rise, bear weight, and stand long enough to assess tolerance?
4
Step
Can the patient march or walk independently without an assistive device and without physiologic fall concerns?
BMAT Level 4 Note
BMAT Level 4 is modified independence: the patient can march or walk without hands-on assistance or a support device, while the nurse still uses judgment about supervision and precautions. If the safe plan includes a walker, cane, standby/minimal assist, or another support, document a Level 3 plan with the device, assist level, supervision, and precautions.
Interactive: Try Your Own Patient
Free Practice Level Builder
Use this quick builder after learning the four maneuvers. Check any safety issue that applies, then choose the first maneuver the patient cannot safely complete. If the patient can complete every step safely without a support device or hands-on assist, choose Level 4.
Listening mode pauses after this tool is explained. Try one or two recommendations, then use Continue Audio at the bottom of the builder when you are ready to keep listening.
Audio paused for practice. Try the builder, then use Continue Audio below when you are ready.
Safety screen
First unsafe maneuver
-
Select the safety screen and first unsafe maneuver to see a recommendation.
Coaching While You Test
- Explain what you are asking before touching or moving the patient.
- Keep the bed low and locked before standing. Clear lines, drains, oxygen tubing, and the path.
- Guard closely during transitions. Many patients look fine lying down and declare themselves during the first sit or stand.
- Stop for dizziness, buckling, severe pain, dyspnea, chest pain, new confusion, or inability to follow direction.
- Document what the patient actually did, not just what you hoped they could do.
Bedside Takeaway
BMAT is progressive. You are not trying to make the patient pass. You are trying to identify the safest current level and stop before the transfer becomes a rescue.
Clinical Scenario
Your patient can sit at the edge of the bed and move both legs against gravity, but when they try to stand their knees buckle and they grab the side rail.
What does BMAT change about your next move?
AudioGuided teaching trackRecommended
Recommended for most learners: press play and let the transcript follow the page. The audio pauses at practice activities when needed; Read mode remains available if you prefer text only.
Transcript lines are timed from the generated recording and can be clicked to jump within the audio.
Module 3: From BMAT Level To Equipment
BMAT Is A Bridge To A Mobility Plan
The level is not the finish line. The level should drive the next safe action: in-bed mobility, chair positioning, dependent transfer equipment, sit-to-stand technology, gait belt or walker use, staff assist, PT/OT referral, or provider clarification.
Start with the current BMAT finding
Choose the safest plan based on what the patient actually demonstrated today.
Level 2
Sits and participates, but not safe to stand
Protect the patient from a failed stand. Use equipment that does the lift unless sit-stand criteria are clearly met.
Level 3
Stands or bears weight, but needs device or assist
Plan the transfer around observed strength, stepping, balance, and baseline device use.
Level 4
Independent or modified independent without device
Encourage routine mobility when clinically appropriate while still using fall-prevention judgment.
No routine SPH equipment
Continue fall-prevention, line, oxygen, medication, and environment judgment.
| Current BMAT Finding | Thompson Equipment / Mobility Plan | Local Teaching Point |
|---|---|---|
| Level 1 - dependent or unable to safely sit/reach | Use ceiling/portable/total mechanical lift for dependent chair transfers. For lateral transfers, boosting, turning, or repositioning, use Comfort Glide or PATRAN with trained staff. | If movement is needed before BMAT is documented, use the highest level of equipment until a licensed nurse completes and documents a validated assessment. |
| Level 2 - sits and participates, but not safe to stand | Do not walk or pivot. Use ceiling/portable lift, Comfort Glide/PATRAN, or a mechanical sit-stand only when criteria are met: seated balance, partial weight-bearing, cognition, and no contraindication. | The Thompson RN Reference Tool notes that standing/transfer with a mechanical sit-stand should be performed with PT first. |
| Level 3 - bears weight or stands, but needs device/assist or cannot walk independently | Use gait belt, manual stand aid, walker/assistive device, or sit-to-stand plan based on training and policy. Stop before ambulation if stepping is unsafe. | If the patient uses an assistive device at baseline, document the device, assist level, supervision, and precautions with the Level 3 plan. |
| Level 4 - modified independence / independent without device | No safe-patient-handling equipment is expected for routine mobility. Encourage mobility three times per day when clinically appropriate and document observed mobility. | BMAT Level 4 still leaves room for clinical judgment about supervision. It does not cancel fall prevention, line/oxygen management, medication effects, or care-context judgment. |
Safe Patient Handling Setup
Before moving the patient, set up the room and the team. Use a wide stable base, face the direction of movement, avoid twisting, keep the patient close, lock the bed and target surface, lower rails to reduce reach, and set bed height around hip level for moving. Plan the transfer out loud, tell the patient what you are doing, and ask them to help only as much as they safely can.
Safe Patient Handling Principle
Manual lifting is not a backup plan for missing equipment. Thompson policy says no individual should manually lift patients weighing more than 35 pounds without an assistive device or safe patient handling equipment appropriate for that task.
Thompson Equipment Quick Reference
| Equipment | Use It For | Thompson-Specific Reminders |
|---|---|---|
| PATRAN slide sheet | Lateral transfer, boosting, turning, repositioning | Use the draw sheet/linens as handles; do not pull the PATRAN itself. Remove it after the move. Find through storeroom or patient care supply areas. |
| Comfort Glide | Air-assisted lateral transfer or repositioning | Minimum 2 staff, 3 preferred. Capacity listed in Thompson materials as 1,000 lb; use 2 pumps if patient is over 500 lb. The mat can remain under the patient with hose detached. |
| Total mechanical lift / Hoyer / ceiling lift | Dependent transfer, non-weight-bearing, poor sitting balance, unable to follow commands | Use two or more caregivers. Inspect slings. Ceiling lifts are in the intensive care unit; portable/full mechanical lifts and slings are in common patient care supply areas or clean utility rooms. |
| Mechanical sit-stand | Seat-to-seat transfer for partial weight-bearing patient with good cognition and sitting balance | Two or more caregivers. Useful for toileting/pericare. Check contraindications such as certain recent abdominal, cardiac, respiratory, aneurysm, or rib-fracture concerns. |
| Manual stand aid | Patient who can bear weight, has fair upper-extremity strength, good sitting balance, and minimal-assist sit-to-stand ability | Lock wheels during transfer. Patient feet go on platform, knees against shin pads, and patient pulls using their own strength. |
| Gait belt / walker | Assisted rising, transfer, or ambulation when patient can move feet and does not need to be lifted or held up | A gait belt is not a rescue device for collapse risk. If the patient may buckle or fall, use sit-stand or total lift planning instead. |
| HoverJack | Clinically cleared patient after a fall or other vertical lift when weight/girth makes manual lifting unsafe | Capacity listed as 1,200 lb. Use at least 2 caregivers, preferably 3-4. Never leave the patient unattended while inflated. Thompson quick reference lists locations including Nursing Admin, ED, and 3E. |
Capacity Check
Thompson's quick reference lists common capacities, but equipment models vary. Check the label on the actual device and sling before use. For unclear or complex transfers, involve the SPH unit representative or safe patient handling resource.
Optional Thompson Reference Files
For local equipment details, storage notes, and communication tools, keep these Thompson source references nearby:
Who Leads The Move?
A licensed nurse performs and documents the validated mobility assessment. Hospital unlicensed assistive personnel and certified assistive personnel may move or transfer after the assessment is completed and documented. Non-Thompson employees, agency staff, students, and site security personnel are not lead personnel for lifting/transferring/transporting, except EMS transferring patients in the ED and upon discharge.
Interactive: Pick The Safer Plan
Transfer Decision Practice
Listening mode pauses after this activity is explained so you can finish the transfer scenarios before continuing.
Audio paused for practice. Finish the transfer scenarios and it will resume automatically.
Scenario 1 of 4
When To Bring In PT/OT
BMAT supports nursing decisions, but it does not replace PT/OT. In general, nursing should escalate when the patient has a new mobility decline, new focal weakness, repeated orthostatic symptoms, unsafe gait, complex equipment needs, new discharge concerns, or a mobility plan that is not improving.
For patients in the intensive care unit, Thompson's A-F Bundle says all patients should have PT/OT consults when medically stable and able to participate with activity. The MOVES note also clarifies that if a patient is presenting at baseline, no PT/OT evaluation is needed; therapy needs a prior level of function to work toward, functional goals, potential to progress, ability to actively participate, and medical criteria for safe mobility. PROM alone is not skilled therapy.
Bedside Takeaway
BMAT should prevent "we just got them up" from turning into a fall or staff injury. Match the plan to what the patient demonstrated, not what you wish they could do.
Clinical Scenario
An intensive care unit patient is awake on high-flow nasal cannula after extubation. They are still weak, have multiple lines, and want to sit in the chair for lunch.
What is the best BMAT mindset?
AudioGuided teaching trackRecommended
Recommended for most learners: press play and let the transcript follow the page. The audio pauses at practice activities when needed; Read mode remains available if you prefer text only.
Transcript lines are timed from the generated recording and can be clicked to jump within the audio.
Module 4: Applying BMAT Across Patient Care
Core BMAT Practice
Across patient care settings, mobility decisions often include oxygen needs, monitoring, orthostasis, exertional symptoms, medications, recovery from sedation or anesthesia, procedure timing, and line management. BMAT is especially useful before toileting, transfer to chair, first walk after admission, post-op progression, procedure/imaging transfers, and any time the patient's condition changes.
Inpatient Example
A post-op patient on opioids reports feeling "a little woozy." They pass sit and shake but become pale and dizzy on standing. Stop. Return to safety, reassess vitals, notify as needed, and document the observed limitation. The right answer is not "try faster."
Choose Your Practice Cases
Choose the option that best fits the patients you may care for, then complete the cases that appear.
Choose one option before starting the guided cases.
Audio paused here. Choose an option to continue.
Non-Ventilated Patients: What To Know
Use this section to practice spotting when the patient's response changes the mobility plan. Symptoms, tolerance, participation, and unclear history should guide the safest next move.
| Finding | What To Do |
|---|---|
| Dizziness, pallor, severe dyspnea, buckling, new confusion, or inability to follow directions | Stop progression, support the patient, reassess, and choose a safer mobility plan. |
| Patient can participate but cannot complete the next BMAT step safely | Use the observed limit to guide assist, equipment, and what you tell the next person. |
| Current mobility history is unclear | Do not let baseline report substitute for current assessment. |
Quick Rule
The safest plan follows what the patient demonstrates right now.
Ventilated / Critical Care-Level Path: A-F Bundle And MOVES
This path includes ventilated-patient readiness and critical care-level mobility decisions, but the same BMAT foundation still matters. Patients may be coming off sedation, recently extubated, on high-flow oxygen, managing lines or drains, experiencing delirium, recovering from vasoactive medication changes, or ready to progress toward chair or ambulation. The A-F Bundle gives structure for this work, with MOVES adding the readiness screen when ventilated-patient complexity is present.
These mobility decisions require more coordination, but immobility is not benign. Thompson's A-F Bundle states that early mobility is safe and achievable in many critically ill patients, and that initiating therapy as soon as possible can reduce delirium days, decrease ventilator time and intensive care unit and hospital length of stay, prevent deconditioning, ventilator-associated pneumonia, and pressure ulcers, and support return toward pre-admission activity.
The A-F Bundle also says all elements should be addressed daily during interdisciplinary rounds, patients should be mobilized to their potential daily, BMAT should be completed on admission or transfer to the intensive care unit and at least once per 12-hour shift, and mobility assessments/interventions by the multidisciplinary team should be documented in the EMR.
| MOVES Screen | Thompson Readiness Cue |
|---|---|
| M - Myocardial stability | No ischemia for 24 hours, no dysrhythmia requiring new IV antiarrhythmic agents for 24 hours, resting HR consistently under 120, and no hypertensive emergency. |
| O - Oxygenation adequate | Examples from policy include FiO2 less than 0.6, PEEP less than 10 cm H2O, RR under 30 at rest, and attention to recent intubation/tracheostomy status. |
| V - Vasopressors | No increase of any vasopressor for 2 hours. |
| E - Engages / able to participate | Able to respond and follow cues safely, maintain alertness, actively cooperate, and SAS 4: calm and cooperative. |
| S - Special considerations | Labs reflect Hgb greater than 7, platelets greater than 20,000, and pH greater than 7.25; discuss mobility with provider for lumbar drain, pulmonary artery catheter, transvenous pacer, or transcutaneous pacer; review open abdominal incision, unstable fracture, active hemorrhage, neuromuscular blockade, and thrombolytic therapy in the previous 24 hours. |
MOVES Quick Practice
A ventilated patient is awake, calm/cooperative with SAS 4, follows cues, FiO2 is 0.45, PEEP is 8, HR is 92, and vasopressors have not increased for 3 hours. What is the best next step?
OB/Postpartum Patients: What To Know
Use BMAT for the current mobility assessment, and add obstetric fall-risk thinking when physiology or recent care may make the patient unsafe even if they look strong in bed. Published obstetric fall-risk work notes that general fall tools may miss risks tied to pregnancy, delivery, neuraxial anesthesia, blood loss, medications, and first postpartum ambulation.
| OB/Postpartum Risk Cue | BMAT Implication |
|---|---|
| Epidural, spinal, or general anesthesia in the last 24 hours; reduced sensation; leg heaviness; or function changes after pushing/birth | Start low, verify current sensation and motor control, and stop if sitting, leg control, standing, or stepping is not safe. |
| First time out of bed postpartum, prolonged bedrest/labor, sleep deprivation, or exhaustion | Treat first ambulation and toileting as a high-risk moment, even when baseline mobility was independent. |
| Magnesium, opioids/Nubain, antihypertensives, sedatives, benzodiazepines/anxiolytics, promethazine, Benadryl, or other sedating/hypotensive medications | Watch alertness, dizziness, orthostasis, coordination, and ability to follow cues before progressing. |
| Postpartum hemorrhage of 1,000 mL or more, symptomatic anemia, sepsis signs, hypotension, tachycardia, fever, edema, or significant pain | Do not let bathroom urgency or discharge pressure override symptoms. Use safer toileting/transfer options and escalate as needed. |
| Pregnancy-related center-of-gravity or gait changes, incision pain, sciatica, symphysis pubis dysfunction, urinary urgency/frequency, or indwelling catheter | Match the mobility plan to what the patient can safely demonstrate now, including assist level, device, staff support, and precautions. |
OB Safety Point
A postpartum patient can pass strength tasks and still need added precautions because of sensation changes, fluid shifts, blood loss/anemia, medication effects, vasovagal response, pain, or first ambulation after many hours in bed.
Guided Scenario Practice
Practice Assessment
Choose an option above, then work through five short cases. For each case, decide what changes the plan: symptoms, tolerance, participation, equipment needs, and what the next person needs to know.
Listening mode pauses after this activity is explained so you can complete the guided cases before continuing.
Audio paused for practice. Finish the guided cases and it will resume automatically.
Path required
Urgent Or Unscheduled Mobility
Some mobility decisions happen quickly: bathroom requests, imaging pressure, stretcher-to-chair moves, discharge ambulation, and patients who have been waiting in one position for a long time. BMAT helps slow down the exact moment where a fall often happens: "They look okay, let's just get them up."
Fast-Moving Watchouts
Syncope, intoxication, stroke symptoms, trauma, hypoxia, pain medication, behavioral escalation, and long stretcher time can all change mobility quickly. If the safety picture is unclear, use the safer transfer option and reassess.
Postpartum Recovery
For postpartum patients, use the BMAT result alongside the physiologic risks above. A patient who was independent before delivery may still need a lower mobility plan during first ambulation, toileting, recovery from anesthesia, or periods of dizziness, pain, medication effect, bleeding concern, or exhaustion.
Post-Procedure Or Anesthesia Recovery
After anesthesia, procedures, or sedation, mobility decisions often happen around stretcher transfers, first movement, toileting, discharge readiness, and procedure-related restrictions. If the patient cannot participate or has not been assessed, Thompson policy supports using the highest level of equipment until a validated assessment is performed by a licensed nurse and the transfer recommendation is documented.
Imaging And Procedure Transfers
Transfer planning should be communicated before the patient arrives when possible. Table transfers, oxygen or monitoring needs, contrast reaction risk, sedation, lines, drains, and procedural positioning can change the safest plan. If the current BMAT or transfer method is unclear, clarify before moving the patient from stretcher, bed, wheelchair, or procedure table.
Scenario Practice
Practice Decision Check
A 64-year-old admitted with pneumonia is now on 4 L oxygen. They pass sit and shake, but become very short of breath during stretch and point. What is the next move?
Bedside Takeaway
BMAT does not make mobility automatic. Each patient care situation has its own safety screen, and the patient's response should drive the next move.
Clinical Scenario
At 0700 the patient was documented as walking with a walker and one assist. At 1500 they are newly confused and cannot stand without buckling. Transport is waiting to take them to imaging.
What should happen before transport?
AudioGuided teaching trackRecommended
Recommended for most learners: press play and let the transcript follow the page. The audio pauses at practice activities when needed; Read mode remains available if you prefer text only.
Transcript lines are timed from the generated recording and can be clicked to jump within the audio.
Module 5: Document, Hand Off, Escalate
Document What Happened
Good mobility documentation should tell the next nurse what is safe, not just satisfy a field. At minimum, the record should make clear the current BMAT level or mobility status, what the patient actually completed, the assist level, equipment used, tolerance, and any reason the assessment was stopped.
Thompson's safe moving and handling policy says the safe lift/transfer recommendation must be documented in the EMR, and that BMAT documentation is found in Epic flowsheets in the Vital Signs tab under Mobility.
Use Plain Handoff Language
A useful handoff sounds like bedside nursing:
Example Handoff
"Current BMAT is Level 3. She can stand with two assist and a gait belt but cannot step without buckling. Use the stand aid for chair or commode. PT is consulted because this is a new decline from baseline."
Handoff Builder
Reassess When The Patient Changes
Mobility is dynamic. Thompson policy requires BMAT at least daily and as needed when patient status changes. The intensive care unit adds a 12-hour-shift cadence through the A-F Bundle. Reassess when there is new sedation, pain medication, worsening oxygen need, new weakness, delirium, fall, post-procedure restriction, orthostasis, prolonged bedrest, or meaningful improvement. The chart should not quietly carry forward an old level when the bedside picture has changed.
Escalate Early
- Escalate to the provider for new neuro change, syncope, chest pain, severe dyspnea, unstable vitals, or unclear activity orders.
- Escalate to PT/OT for new functional decline, unsafe gait, discharge planning needs, or repeated failure to progress.
- Escalate to the SPH unit representative, safe patient handling resources, or a superuser when the equipment plan is unclear or bariatric/complex transfer support is needed.
- Escalate in handoff when transport, imaging, recovery, procedural, or receiving teams need to know the current transfer method.
- Report injuries or near misses related to lifting/transferring through the associate injury reporting process.
Evidence Notes And References
- Boynton T, Kelly L, Perez A, Miller M, An Y, Trudgen C. The Banner Mobility Assessment Tool for Nurses: instrument validation. American Journal of Safe Patient Handling & Mobility. 2014.
- Boynton T, Kelly L, Perez A, Miller M, An Y, Trudgen C. BMAT 2.0 for bedside nurses. American Nurse Journal. 2020.
- Kalisch BJ, Lee S, Dabney BW. Outcomes of inpatient mobilization: a literature review. Journal of Clinical Nursing. 2014.
- Zisberg A, Shadmi E, Sinoff G, Gur-Yaish N, Srulovici E, Admi H. Low mobility during hospitalization and functional decline in older adults. Journal of the American Geriatrics Society. 2011.
- Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet. 2009.
- Devlin JW, Skrobik Y, Gelinas C, et al. Clinical practice guidelines for prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult intensive care unit patients. Critical Care Medicine. 2018.
- NIOSH/CDC and OSHA safe patient handling and mobility guidance for reducing caregiver musculoskeletal injury risk.
- Agency for Healthcare Research and Quality. Early mobility programs and tools for hospitalized and critically ill patients.
- Heafner L, Suda D, Casalenuovo N, Leach LS, Erickson V, Gawlinski A. Development of a tool to assess risk for falls in women in hospital obstetric units. Nursing for Women's Health. 2013;17(2):100-107. doi:10.1111/1751-486X.12018.
- Frank BJ, Lane C, Hokanson H. Designing a postepidural fall risk assessment score for the obstetric patient. Journal of Nursing Care Quality. 2009;24(1):50-54.
- Weigand A, Kathman J, Colton J, Davis J. Comparative analysis of two fall risk assessment tools in the obstetric population. Nursing for Women's Health. 2025;29(2):82-89. doi:10.1016/j.nwh.2024.10.005.
- UR Medicine Thompson Health. CC.15.004.07 Safe Patient Moving and Handling. Last revised/effective May 5, 2026.
- UR Medicine Thompson Health. CC.13.001.57 Guidelines for Management of Mechanically Ventilated Patients (A-F Bundle). Last revised/effective April 5, 2026.
- UR Medicine Thompson Health. Safe Patient Handling Training. Local training document provided May 2026.
- UR Medicine Thompson Health. BMAT RN Reference Tool - FFTH; BMAT Communication - FFTH; SPH Quick Reference - Thompson. Local reference materials provided May 2026.
Final Assessment
Answer all 12 questions. A score of 10/12 or higher is required for completion.
1. What is the primary purpose of BMAT at the bedside?
Correct. BMAT connects what the patient can safely do now with the safest assist, equipment, and escalation plan.
Not quite. BMAT is a nursing bedside decision tool for current mobility and safe patient handling. It does not replace PT/OT or one-time fall risk documentation.
2. Which finding should stop BMAT progression before standing?
Correct. New dizziness and pallor are stop signs. Support the patient, reassess, and escalate as needed.
The stop sign is the new symptom. Baseline walker use affects the plan and documentation, but it does not automatically stop assessment.
3. A patient cannot sit upright safely or reach to shake your hand. What is the safest BMAT interpretation?
Correct. If the patient cannot complete the first maneuver safely, do not progress to higher-demand tasks.
BMAT starts low and progresses only when safe. A home baseline does not override the current bedside finding.
4. A patient can sit and reach but cannot demonstrate safe leg control during stretch and point. What should you avoid?
Correct. Failing the seated leg control step means the plan should change before attempting higher-risk standing or walking.
Documentation, help, and equipment are appropriate. The unsafe move is progressing to walking or pivoting despite a failed lower-level maneuver.
5. A patient can stand and walk only with their baseline walker. What should the nurse document?
Correct. A walker means the patient still needs a support device. Document Level 3 with the walker, assist level, supervision, and precautions.
Level 4 is modified independence without hands-on help or a support device. A walker plan needs clear Level 3 documentation.
6. Which statement best reflects safe patient handling principles?
Correct. The plan should match patient participation, equipment criteria, and trained staff availability.
Safe patient handling is not about staff strength. Equipment and trained help reduce injury risk for both patient and staff.
7. A patient cannot sit upright safely or participate in the first BMAT step, but needs to move from bed to stretcher. Which plan best matches the finding?
Correct. A patient who cannot safely sit, reach, or participate should not be progressed to standing or pivoting. Match the move to dependent or lateral transfer equipment.
The current bedside finding matters more than baseline report, urgency, or who will reassess later. Do not progress to edge-of-bed, standing, or pivoting when the first BMAT step is unsafe.
8. A patient sits and follows directions, but their knees buckle during the stand attempt. They urgently need toileting. What is safest?
Correct. Buckling is a stop point. Urgency does not make an unsafe pivot safer; choose the toileting plan and equipment that match what the patient demonstrated.
A failed stand means the plan changes before transfer. Do not use family, motivation, or urgency as a substitute for equipment and staff planning.
9. A patient was walking with a walker this morning but is now newly confused and buckling. What should the nurse do?
Correct. Mobility changes require reassessment, documentation, handoff, and often escalation.
A previous level is not safe when the patient's current condition has changed.
10. Which patient is the best match for a manual stand aid?
Correct. A manual stand aid requires patient participation, sitting balance, weight-bearing ability, and enough arm strength to pull with their own strength.
A manual stand aid is not for a dependent, nonparticipating, or buckling patient. Choose equipment that provides the level of support the patient actually needs.
11. A patient is going for an imaging study. Which mobility handoff is most useful?
Correct. Good handoff tells the receiving area or transport what was observed, what transfer plan is safe, and what safer fallback to use if the preferred equipment is not available.
Vague baseline statements are not enough. Handoff should include current level, observed ability, limits, equipment plan, and safer fallback.
12. What is the best final habit for BMAT use?
Correct. That is the practical BMAT rhythm.
BMAT is not about forcing progression or saving time. It is about matching the current patient to a safe mobility plan.
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