Berg Balance Scale Fall Risk Assessment

Inspection template for administering and scoring the 14-item Berg Balance Scale (BBS) to document functional balance performance and stratify fall risk.

Assessment Setup and Safety

• Patient identity and assessment date/time confirmed
  Document the patient identifier and when the assessment was performed.
• Assistive device use documented
  Record whether the patient used an assistive device during the assessment.
• Environment clear and safe for balance testing
  Ensure floor space is unobstructed, chair is stable, and testing area is appropriate for standing and reaching tasks.
• Patient able to follow simple commands
  Confirm the patient can understand and respond to standardized instructions for the assessment.

Berg Balance Scale Item Scores

• Sitting to standing
  Observe the patient rising from sitting to standing without using hands if possible.
• Standing unsupported
  Assess ability to stand without support for the required duration.
• Sitting unsupported
  Assess ability to sit without back or arm support.
• Standing to sitting
  Observe control and safety when lowering from standing to sitting.
• Transfers
  Assess ability to transfer between chairs or surfaces safely.
• Standing with eyes closed
  Assess postural stability while standing with eyes closed.
• Standing with feet together
  Assess ability to stand with feet together without losing balance.
• Reaching forward with outstretched arm
  Assess how far the patient can reach forward while maintaining balance.
• Retrieving object from floor
  Assess ability to bend and retrieve an object from the floor safely.
• Turning to look behind
  Assess trunk rotation and balance while looking over the shoulder.
• Turning 360 degrees
  Assess ability to turn completely in both directions without loss of balance.
• Placing alternate foot on stool
  Assess ability to alternately place each foot on a stool or step.
• Standing with one foot in front
  Assess tandem stance stability with one foot directly in front of the other.
• Standing on one foot
  Assess single-leg stance balance and control.

Total Score and Fall Risk Interpretation

• Total Berg Balance Scale score
  Enter the total score from 0 to 56 based on the 14 item scores.
• Fall risk interpretation
  Select the overall fall-risk category based on the total score and clinical judgment.
• Recommended follow-up or intervention
  Document any recommended therapy, mobility support, reassessment interval, or referral.