Healthcare Zero Lift Protocol

Healthcare Zero Lift Protocol

Facility and Policy

Facility Name:   Effective Date:

Policy Statement: The facility maintains a Zero Lift Protocol requiring the use of mechanical lifting devices for all transfers and repositioning when the patient requires assistance beyond independent ability. Manual lifting of patients by staff is prohibited except in an immediate life-safety emergency where mechanical devices are unavailable. Staff shall follow device manufacturer instructions and facility competency requirements at all times.

Patient Information

Date of Birth:   Gender:

Primary Phone:   Emergency Contact:   Phone:

Insurance Information

Policy Number:   Group Number:   Subscriber Name:

Medical History (Relevant to Mobility)

Mobility Assessment

Assessment Date:   Assessed By (Printed Name & Title):

Mobility Status (check all that apply):
Independent without assistance    Requires cane    Requires walker    Uses wheelchair    Non-ambulatory

Fall Risk: Yes    No    If yes, describe precautions:

Zero Lift Transfer Plan

Transfer Level Required: Full mechanical lift (patient fully dependent)    Sit-to-stand or partial mechanical assist    Bariatric lift required

Exceptions to Zero Lift Policy: Manual lifting is prohibited except in an immediate life-safety emergency where delaying transfer would result in greater harm. Any manual lifting in emergency circumstances must be documented in the clinical record and reported per facility policy.

Risks, Benefits, and Consent

Risks and Benefits Statement: I acknowledge that I have been informed that the use of mechanical lifting devices is intended to reduce risk of injury to both patients and staff. Risks associated with mechanical lifting devices may include skin shear, discomfort, anxiety, rarely equipment malfunction, or transfer-related incidents. Benefits include safer transfers, reduced fall risk, and reduced manual handling injuries. Alternatives to mechanical lifting were discussed, including sole reliance on manual assistance (not recommended) and delaying transfers until additional staff or equipment are available.

Consent: By signing below I authorize facility staff to perform transfers and repositioning using mechanical lifting devices consistent with this Zero Lift Protocol and the Transfer Plan above. I understand I may withdraw consent at any time, subject to clinical judgment for safety; withdrawal will be documented and discussed with me. I further understand that staff will make reasonable efforts to comply with my preferences while maintaining safety.

Staff Training and Competency

Staff Verified Competency: All staff performing transfers for this patient have completed required training and demonstrated competency in the use of specified equipment. Training date: . Names of staff trained for this plan:

Privacy and Information Sharing

Authorization to Share Information: I authorize the disclosure of relevant health information to facility staff, contractors, and other authorized individuals solely for the purpose of planning and performing safe transfers under the Zero Lift Protocol. This includes transfer requirements, mobility assessment findings, and equipment specifications.

I acknowledge that I have received the facility's privacy notice regarding use and disclosure of health information for care coordination and transfer safety.

Authorization Duration

This authorization and transfer plan shall remain in effect until: or until revoked in writing by the patient or authorized representative.

Documentation and Incident Reporting

All transfers performed under this plan must be documented in the clinical record including device used, staff involved, time, and any adverse events. Any incident involving manual lifting in an emergency must be documented and reported per facility policy.

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