Title Page

  • Site conducted

  • Prepared by

  • Conducted on

Observation Details

  • List names of Employees being observed

  • Observer

  • Total Time Observed


  • Does the clinic appear clean and free from clutter?

  • Are all hallways, treatment areas, corridors, and exits free of obstruction?

  • Is the floor/carpet clean, dry, and free of holes or tripping hazards?

  • Is the furniture and equipment in good repair?

  • Does the placement of equipment meet manufacturer's guidelines/requirements? For example, the Lifestyle cable column has a clear three-foot radius.

  • Is the gym equipment properly placed for safety when in use?

  • Was the gym equipment properly stored after patient use to ensure staff and patient safety.


  • What precautions were used by the therapist to ensure safety when treating a patient at risk for falls? Select all that apply.

  • Did you observe the therapist using a gait belt on patients who are at risk for falls?

  • Did the therapist use proper set up of the exercise to ensure safety? i.e., free of hazards; providing patient assist to reduce complexity and load.

  • Did the therapist ensure safety with the intervention performed by the patient? i.e., providing proper instruction of the exercise and observation of the return demonstration of the exercise; provide proper supervision of the patient based the observation of the return demonstration of the exercise.

  • Did the therapist use clinical judgement to alter the complexity of an exercise to improve safety?

  • Was the Physical Therapy Aide used in the supervision of a patient at risk for falls? If yes, describe supervision.

  • Did you observe the physical therapy aide providing exercise instruction to a patient that has not previously completed that exercise?

  • Did you observe the physical therapy aide altering treatment to reduce complexity, increase complexity, and/or improve safety without consultation with the treating therapist?

  • Did you observe any near misses in the clinic?

  • How many?

  • Did you witness any unsafe events in the clinic? If yes, please describe.


  • How many patients were seen in the clinic during your observation hours?

  • How many patients during your observation were deemed fall risk?

  • Were patients scheduled appropriately to ensure safety and reduce fall risk?

  • If the patient was deemed a fall risk, was there a falls assessment completed on the patient within the last 30 days?

  • If precautions were used by the therapist to improve the safety of the patient, did the therapist document the precautions in the daily note?


  • Based on the observation; was best practice followed to ensure the safety of the patients/visitors/staff?

  • What are your recommendations?

  • Follow up actions

  • Date for actions to be completed:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.