Timed Up and Go Test Documentation
Timed Up and Go Test Documentation records baseline and reassessment times, mobility observations, and fall-risk follow-up in one clinical form. Use it to standardize TUG results and make changes in mobility easier to compare over time.
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Built for: Physical Therapy · Primary Care · Geriatrics · Home Health · Rehabilitation
Overview
This Timed Up and Go Test Documentation template records the essential details of a TUG assessment in a structured format: test context, baseline mobility, timed results, and fall-risk follow-up. It is built for clinicians who need a consistent way to document how a patient performed, what support was required, and whether the result suggests increased fall risk.
Use this template when you want a repeatable record for baseline screening, reassessment after treatment, or follow-up after a change in mobility. The form is especially useful when the same patient is tested more than once and you need to compare times alongside observed difficulty, assistive device use, and whether the test was completed without stopping. It also helps when the result needs to be shared across care teams or stored in a chart with an audit trail.
Do not use this form as a general intake or full functional assessment. It is not meant to replace a broader gait, balance, or neurologic evaluation, and it should not be overloaded with unrelated history fields. If the patient cannot safely complete the test, document the reason and the observed limitation rather than forcing a result. The template works best when the fields are filled with direct observations, minimal necessary data, and a clear follow-up plan when fall risk is a concern.
Standards & compliance context
- If the form is shared with patients or caregivers, keep the layout accessible and readable in line with WCAG 2.1 AA principles.
- Collect only the minimum necessary clinical information needed to document the TUG result and follow-up, consistent with data minimization practices.
- Avoid adding unrelated identifiers or sensitive history fields unless they are needed for care, billing, or the clinical workflow.
- If the template is used in a regulated clinical record, preserve an audit trail for edits, reassessments, and clinician sign-off.
General regulatory context for orientation only — verify current requirements with counsel or the relevant agency before relying on this template for compliance.
What's inside this template
Test Context
This section anchors the assessment in the correct visit, time, and setting so the result can be interpreted in context.
- Assessment Type
- Assessment Date
- Assessment Time
- Assessment Setting
Patient Mobility Baseline
This section captures the patient’s starting mobility status and any support used before the timed test begins.
- Assistive Device Used
- Required Physical Assistance During Test
-
Baseline Mobility Notes
Briefly note relevant mobility limitations, balance concerns, or precautions. Do not include unnecessary PII.
Timed Up and Go Results
This section records the actual performance data and observed difficulty that determine how the test should be read.
-
Baseline Time (seconds)
Enter the time in seconds for the rise, walk 3 meters, turn, return, and sit sequence.
-
Reassessment Time (seconds)
Enter the reassessment time in seconds if this is a follow-up test.
- Completed Test Without Stopping
- Observed Difficulty
Fall Risk and Follow-Up
This section turns the test result into action by documenting whether risk is a concern and what happens next.
- Fall Risk Concern
- Follow-Up Recommended
-
Clinician Notes
Add concise interpretation, precautions, or next steps. Collect only information needed for care.
How to use this template
- 1. Enter the assessment type, date, time, and setting so the TUG result is tied to the correct visit and care environment.
- 2. Record whether the patient used an assistive device, needed physical assistance, and any baseline mobility notes before the timed test begins.
- 3. Capture the baseline and reassessment times in seconds, and note whether the patient completed the test without stopping or showed observed difficulty.
- 4. Mark whether fall risk is a concern and indicate whether follow-up is recommended based on the observed performance and clinical judgment.
- 5. Add concise clinician notes that explain the result, any safety concerns, and the next action, such as referral, repeat testing, or mobility support.
Best practices
- Use a numeric input for test times and record seconds consistently so reassessments can be compared without conversion errors.
- Document the assistive device exactly as used during the test, because a cane, walker, or no device changes how the result should be interpreted.
- Capture whether the patient stopped, hesitated, or required cueing during the test, not just the final time.
- Keep baseline mobility notes specific and observable, such as unsteady turns, slow sit-to-stand, or guarded gait, rather than vague summaries.
- Use conditional logic to show follow-up fields only when fall risk is flagged, so the form stays short when no escalation is needed.
- Mark required fields clearly and leave nonessential clinical context optional to support data minimization and faster completion.
- Include a clear submission confirmation or charting note so staff know whether the documentation is final, pending review, or routed for follow-up.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
What is this Timed Up and Go Test Documentation template used for?
This template captures the core parts of a TUG assessment: test context, baseline mobility, timed results, and fall-risk follow-up. It is designed for documenting a single screening or reassessment in a consistent format. Use it when you need a repeatable record that can be compared across visits or care settings.
Who should complete this form?
A clinician, therapist, nurse, or other trained staff member should complete it after observing the test. The form includes clinical observations, so it works best when the person documenting the result can confirm whether the patient used an assistive device, needed physical assistance, or stopped during the test. If your workflow allows delegated collection, the final review should still be done by a qualified clinician.
How often should the TUG be documented?
Use it at baseline, after a change in condition, and during planned reassessments. The template includes both baseline and reassessment time fields so you can compare performance over time without changing the structure of the record. Many teams also use it after falls, medication changes, or mobility-related therapy updates.
Does this template support fall-risk documentation?
Yes. It includes a fall-risk concern field and a follow-up recommendation section so the result is not just a number. That makes it easier to document whether the test suggests additional evaluation, gait support, therapy referral, or safety planning. The clinician notes field can capture the reasoning behind the next step.
What are the most common mistakes when filling out this form?
Common mistakes include leaving out the setting, recording times without noting whether the test was completed without stopping, and failing to document assistive device use. Another frequent issue is writing vague mobility notes that do not explain what was observed. The template is most useful when the fields are filled with specific, observable details.
Can this template be customized for different care settings?
Yes. You can add fields for clinic location, therapist name, diagnosis context, or a standardized mobility scale if your workflow needs it. Keep the form focused on the minimum necessary information and use conditional logic if some follow-up fields only apply when fall risk is flagged. That helps preserve usability and reduces unnecessary data entry.
How does this compare with documenting the test in free text notes?
Free text notes are flexible, but they make it harder to compare results across visits and can lead to missing key details. This template standardizes the fields that matter most for TUG documentation, including timing, observed difficulty, and follow-up. It also makes review faster because the important data points are in predictable places.
Can this form be used in an EHR or other system?
Yes. The fields map well to structured data entry in an EHR, intake workflow, or clinical form builder. The time fields should use numeric validation, and the date and time fields should use the appropriate picker controls rather than free text. If you integrate it into a larger workflow, keep the submission confirmation clear so staff know what happens after the record is saved.
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