On Wednesday, Nov. 29, the Bedside Mobility Assessment Tool (BMAT) in Epic will be updated to version 2.0 with improved documentation and workflows to help med/surg nurses assist with identifying patient safety and fall risks. The BMAT provides instructions to assess a patient’s ability to walk independently or with an assistive device.
The new BMAT 2.0 is available in Epic under the Musculoskeletal activity in the Complex Assessment flowsheet. It only takes about two minutes to complete. It should be administered at the time of admission, at least once per shift and with any significant changes in a patient’s status. The assessment is pass or fail, followed by nursing interventions.
The tool also:
- Clarifies how to perform assessments and determines pass or fail.
- Assists with progression from Level 3 to Level 4.
- Provides instructions on the use of walkers, canes, crutches and prosthetic legs and helps progress patients using these devices.
- Supports bilateral, non-weight-bearing patients and bed rest orders with a focus on previous level of function (PLOF).
- Facilitates mobility-related discharge planning.
- Provides goals for ambulating patients who pass all four assessments.
After the patient passes or fails, use the following nursing interventions:
- Mobility (Level 1) – Sit & Shake: Evaluates core strength, sitting tolerance, balance and hemodynamic stability in response to sitting upright.
- Mobility (Level 2) – Stretch: Evaluates a patient’s ability to engage leg and foot muscles. It assesses leg strength and foot-drop contracture deformity and is a precursor to weight-bearing.
- Mobility (Level 3) – Stand: Evaluates the patient’s ability to stand, tolerate standing and maintain standing balance, which are precursors to ambulation.
- Mobility (Level 4) – Step: Evaluates the patient’s ability to step in two parts, march in place and advance step and return with one foot then the other. This is a precursor to ambulation.
Before the Nov. 29 change, all med/surg nurses and nursing managers should complete BMAT training (course #1602006) in LMS and review the BMAT 2.0 Quick Start Guide.
