UNDERSTANDING THE FIM Functional Independent Measure Part 4

Important Reminders You must understand the definition of the each item in order to document accurately Do NOT merge tasks Do not rate simulations, clinical judgments NEVER copy and paste from a previous document because your FIM scores will not be recorded

Important Reminders A number does not support a number! (You must supply detailed documentation within the document.) Min, Mod or Max does not support a number. (You must document why the need the assistance, i.e., decreased balance, decreased strength) “More than reasonable time” to complete a task independently is defined as 3 times the norm and would be scored as modified independence (6).

Important Reminders If in a hurry & don’t have time to allow the patient to do a task & the therapist/nurse does it for the pt, this is max assist. Consider: How much assist did the pt require in this point in time? Who performed the task? Do not modify the assist in order to factor in how busy you are. If you do perform the task for a patient due to your time constraints, document the assistance and the reason (i.e. time constraints) this level was needed to perform the task.

Important Reminders Plan the care you provide by allowing adequate time for the patient to perform the task versus performing the task for the patient. This is rehab, doing the task for the patient should be a rare occurrence.

Transfers: Tub, Shower - Definition Tub: includes getting in and out of a tub Shower: includes getting in and out of a shower

Tub/shower - Considerations Simulations cannot be rated Patient must be fully undressed and wet to rate this item Rating includes the patient’s approach to the tub or shower once the patient is in the bathroom

Tub/shower transfers Note the ability to score only one of these transfers or both shower and tub transfers

Transfers: Toilet Includes safely getting on and off a standard toilet Standard toilet is a regular toilet without attachments such as arm rests or handles to assist patient Includes approach to the toilet once in the bathroom and wheelchair set up

Locomotion/Walk / Wheelchair Sequence

Expected Mode of Locomotion Considerations PT identifies the expected primary locomotion mode at discharge, based on initial assessment PT identifies the primary mode of locomotion achieved at discharge Admission and discharge modes must match

Locomotion: Wheelchair - Definition Wheelchair includes using a manual or motorized wheelchair on a level surface once in a seated position

Locomotion - Considerations P.T. brings an oxygen tank behind is a level 5 If patient is pushed to the gym in a wheelchair, this needs to be assessed as total assist noting the level of assistance provided at that moment in time.

Locomotion: Walk - Definition Walk includes walking on a level surface once in a standing position

Walk - Considerations Score will be affected by both distance and assistance Only include distance without any rest periods or breaks.

Locomotion Walk/WC Exception Exception to distance and assistance rule: If a patient routinely ambulates more than 150 feet throughout the day but is not required to walk 150 feet in every situation, do not consider the distance for that episode of locomotion in the FIM rating, consider only the level of assistance If patient does not perform maximum locomotion distance, do not score this sub max activity. HOWEVER: patient must perform maximum locomotion distance at least once a day.

Locomotion: Stairs - Definition Includes going up and down stairs (one flight) indoors in a safe manner

Stairs - Considerations Score is affected by both number of stairs and level of assistance/use of devices Step height is NOT a factor in rating If patient requires different levels of assistance for ascending and descending the stairs, choose options for the lower rating Stairs must be assessed on admission and discharge. Cannot put “not addressed”.

Note numerous types of assistive device available for stairs

Comprehension - Definition Understanding of either auditory or visual communication (e.g., writing, sign language, gestures)

Comprehension - Considerations Document the amount of assistance required, NOT the measurement of the severity of cognitive deficit Documentation must include the length of time of the interaction AND how much of the day the note represents Patient should not receive a lower score due to English as a second language

Comprehension - Considerations Remember that comprehension needs to include complex or abstract ideas/questions and your assessment must include open ended questions in order to accurately determine the patient’s actual comprehension status. Complex and abstract questions are generally not part of conversation during usual sleep hours and therefore should not be scored.

Expression - Definition Includes clear vocal or nonvocal expression of language. This item includes either intelligible speech or clear expression of language using writing or communication device

Expression - Considerations Remember that expression needs to include complex or abstract information and your assessment must include more than a “yes” or “no” answer. Language of confusion should be considered a deficit. Language may be clearly articulated but if patient is confused at times, this should be assessed in expression.

Social Interaction - Definition Includes skills related to getting along and participating with others in therapeutic and social situations. It represents how one deals with one’s own needs together with the needs of others.

Social Interaction - Considerations In therapeutic and social situations includes In the therapy gym In the dining room During therapeutic group activities During visiting hours with family, friends Sharing room and bathroom with room mate

Social Interaction - Considerations Need to answer three questions Is the patient cooperating? Is the patient participating? Is the patient exhibiting any inappropriate behaviors?

Problem Solving - Definition Includes skills related to solving problems of daily living. This means making reasonable, safe, and timely decisions regarding financial, social, and personal affairs, as well as initiating, sequencing, and self correcting tasks and activities to solve problems.

Problem Solving - Considerations Includes BOTH complex and routine problem solving Includes 5 important skills: Recognizing a problem is present Making appropriate decisions Initiating steps & readjusting to changing circumstances Carrying out a sequence of steps Evaluating the solution

Memory - Definition Includes skills related to recognizing and remembering while performing daily activities in an institutional or community setting. Memory in this context includes ability to store and retrieve information, particularly verbal and visual.

Memory - Considerations Look for information related to the following: Recognizing people frequently encountered Remembering daily routines Executing requests without reminders

Summary Read the prompts carefully each time in order to document accurately Remember we are documenting the burden of care required to help the patient at home perform basic personal tasks Burden of care can be translated into financial cost Careful documentation will support the burden of care and our payments