Frequently Asked Clinical Questions
Questions relating to:
General Scoring
Self Care (Eating, grooming, bathing, upper and lower body dressing, toileting)
Sphincter control
Transfers and locomotion
Cognition
Please send all questions to fim@uow.edu.au
General Scoring
Self Care
Eating
Grooming
Bathing
Upper body dressing
Lower body dressing
Toileting
Sphincter control
Bladder Management
Bowel management
Transfers and locomotion
Bed, chair and wheelchair transfer
Toilet transfer
Walk/Wheelchair
Cognition
Comprehension
Expression
Clinical answers
How do I score
a patient that has died unexpectedly?
Where the end functional scores are unknown and it is not possible to get
an end total, enter 1 for all end FIM™ scores (a total of 18).
This will not effect your units results. All end total scores
of 18 are reviewed by AROC and will be excluded from FIM™ change
calculations in situations like this. SNAPshot user's should
also enter in the comments section of the episode screen type
“FIM 18 used because patient died unexpectedly”.
NOTE: Please ensure you only use a FIM™ total score
of 18 in this manner when the real end score is not known. Do
not simply use a FIM™ score of 18 because someone has died.
We have a patient that had an interruption to their episode of care due to needing acute care, but who is now not going to return the rehab program. How do we end the episode?
This does happen occasionally. As long as it is definite that
the patient will not return to complete their episode the
following steps should be taken:
1. Remove the suspension of treatment date and set suspension to NO
2. Enter the end FIM™ score for the patient*
3. Put the original suspension date as the end date for
the episode
4. Give the appropriate reason for episode end
* For SNAPshot users, where the end FIM™ is unknown and it
is not possible to get an end FIM™, enter 1 for all end FIM™ scores (a total of 18) and in the comments section of the
episode screen type “FIM 18 used because suspension of treatment converted to end date”. This will not effect your units
results. All end FIM™ scores of 18 are reviewed by AROC and
will be excluded from FIM™ change calculations in situations
like this.
NOTE: Please ensure you only use a FIM™ score
of 18 in this manner when it is absolutely impossible to get
the real end score.
Are FIM™ assessment dates essential?
Assessment dates are used to check that the measure is completed
within 72 hours after episode start and and within 72 hours
prior to episode end – they are used as a clinical guide
and are included in the AROC suite of reports. The date that
should be recorded is the date that the assessment actually
took place and not the date it is entered into the computer.
A patient was discharged and the FIM™ scores had been completed. While he was waiting to be transported home, his condition deteriorated and he was transferred to an acute hospital. Should the FIM™ scores reflect his condition at the time of discharge or when he actually left our facility?
We use FIM™ data to measure change within a rehabilitation episode. This gentleman's score should reflect that change prior to the next episode starting. The FIM™ score should therefore reflect his functional ability at the time of discharge and not when he left the facility. You would need to make a comment in the AROC dataset that his mode of episode end was "transferred to another hospital as condition deteriorated post discharge."
High protein diet, low sodium diet,
fluid restriction: are these considered to be diet modifications
and should they be scored 6?
A diet modification is considered to be scored a 6 only if
that modification is for the purposes of assisting with chewing
and/or swallowing ie functions included in the definition
of eating. A high protein or low sodium diet does not assist
with chewing/swallowing so can still score a 7.
Define “customary” manner.
This varies from hospital to hospital. It is the way the food is presented on the tray for that facility, it often includes items like sugar sachets and sometimes even plastic cutlery. If this “customary manner” results in a helper required, the patient would be scored a 5 or less.
Are dentures considered an assistive device?
No. If someone eats with dentures in, they can still score a 7, Independent.
How do you score a patient who's food is cut up by kitchen staff before being presented to the patient? This request is done by the dietician who is filling out the meal requests and the system is being done to save the nurses time; it's not done because the client requires a modified diet or safety concerns.
Cutting up the food prior to "presenting in the customary manner...' it is not included in the scoring for eating, so would not be considered set-up. Since the client does not require food cut up for safety or require a modified diet, you would score a 7, independent.
If someone needs to sit on a chair
to undertake their grooming, is the chair or wheelchair considered
to be equipment, thereby scoring a person who is otherwise
independent as a 6?
The person can still be a 7. Sitting down does not
reduce the score.
Does oral care include managing mouth swabs?
No, oral care includes “brushing teeth” - mouth swabs are seen as a more technical nursing task and not scored in the FIM.
Are electric toothbrushes and electric razors considered assistive devices?
No, because they are commercially available. They are only considered an adaptive/ assistive device if the handle has been specially built up or modified to improve function.
In the community, sanitising gels are used instead of hand washing. The manufacturer recommends that it be washed off once every 24 hours by usual hand washing technique. How would you score this item of grooming if not considering any others?
For the purposes of hand washing within the grooming item, using hand gels is considered as using an assistive device and would be scored as a 6, Modified Independent. Hand washing is defined as washing, rinsing and drying the hands, which is still applicable when using the gel as it is recommended that it is washed off once in a 24 hour period.
How do you score a patient who needs to use the arm of a shower chair to shift their weight from side to side whilst washing their bottom?
Using the armrest of a shower chair is scored down to a 6, modified independence, ONLY if the patient is using the armrest to lift their body to wash, rinse, and dry their bottom.
Is a shower chair or stool deemed an assistive device during bathing?
No. The item bathing refers to the patient’s ability to wash, rinse and dry his body from the neck down. It does not matter if he/ she does this in bed, sitting by the sink or standing in the shower. Using the shower chair is seen as an assistive device to get in and out of a shower (transfers) and should be addressed under the item Bath/ Shower Transfers.
Are hand-held showers considered an assistive device?
They are considered assistive devices if it’s required to wash, rinse and dry the body ie: If the handheld shower were not available, the patient would need assistance from a helper.
How do you score a spinal patient who wears an aspen collar and requires 2 helpers to put in on?
An Aspen collar in an orthotic so you follow the orthotic principles. It is put on at dressing, but does not help with dressing, so it is scored as a 5.
How do we score a patient who does
not wear any underwear for dressing lower body and toileting.
The patient did wear underwear prior to her original hospital
admission. She does wear a skirt that she independently puts
on and adjusts after toileting. She independently attends
to her perineal cleaning. not wearing underwear may be seen
as not wearing appropriate clothing and would this affect
her score. We have all tried to score her but none of us can
agree.
She is wearing a skirt and presumably footwear so she is meeting
the definition for dressing her lower body and can score a
7 if she is independent. With regards to toileting the definition
states "adjust clothing before and after toileting"
so she also meets the definiton for toileting and can score
a 7 for that also.
Could you clarify the score
for toileting for a patient who has an IDC and colostomy and
so does not use the toilet. There is no pulling up or down
of pants or cleaning of the perineal area.
A person who is catheterised or has a colostomy would still
need to manage emptying etc, particularly if they are independent
in looking after these devices. So under toileting, you would
assess their ability to adjust clothing before and after emptying
and whether they can manage cleaning the end of the catheter
etc - so same activities of clothing adjustment before and
after as well as cleansing, but just a different context.
If a patient has renal failure and therefore does not create any urine and has no need to use the toilet? How do you score them in toileting?
The patient is rated at level 7- The patient does not require any assistance with toileting i.e: perineal hygiene and adjusting clothing before and after using the toilet as he/ she does not void.
The item toileting includes both voiding and bowel movements, so you would need to consider the amount of assistance the patient requires for both aspects and if the amount of assistance varies, record the lower score.
How do your score a patient who
wets the toilet seat or floor?
If the patient does not contain his/her urine and has a bladder
spill onto the floor, consider the assistance to clean up
the urine under Bladder Management. If the patient only wets
the toilet seat, do not consider it a urine spill.
How do you score a client that is
using incontinence pads?
A person who wears incontinence pads can score a 6 if the
pads never leak onto the clothing/bed clothes and if that
person manages the pads independently ie changes them themselves.
The client is only classed as having accidents or being incontinent
if their clothing or bed clothes are being soiled/wet. So
if they wear a pad and it does become wet on occasion but
the pants etc remain dry and they manage this themselves they
can score 6 for bladder management.
If someone
wears a pad and has no accidents, i.e. they don't wet their
clothes or the linen, can they be a score of 6 even though
they have a wet pad? They are independent in
the management of the pad.
If a patient wears a pad and manages it independently
they can be a 6 even though the pad is wet/soiled as the definition
of incontinence is "wet or soiled clothing
or bed clothes", the pad is an assistive device therefore scored
at 6.
How do you a score a patient who wears a very large pad to accommodate larger volumes and is “accident free” because clothes and linen remain dry? The pads are expensive and the patient has to dress differently to accommodate their size, but the patient manages them independently.
Score both parts of bladder management:
Part 1: Level of assistance: The pad itself can only reduce the score to a 6 as patient is managing them independently
Part 2: Frequency of Accidents: None, therefore only score part 1.
If the patient needed help to manage the pads because of their size, this would be taken into consideration. If the helper did all the work, you would score a 1, Total Assistance. If the helper provided minimal hands-on assistance you would score a 4, Minimal Assistance.
If a patient has renal failure and therefore does not create any urine and has no need to use the toilet? How do you score them in bladder management?
The patient is rated at level 7- There is no need for assistance and no “accidents” The need for renal dialysis is a result from the kidney impairment and not the bladder. As a result there is no disability related to bladder management.
How do you score medication for bowel management?
If it is recorded on the medication chart, score a 6, Modified Independence. If not e.g: prunes, herbal teas score a 7, Independent.
If a patient has a colostomy bag and does not open his bowels? How do you score bowel management?
You continue to score the 2 parts of bowel management:
Part 1: Level of assistance- You assess how much help the patient needs with managing the colostomy bag. The highest they could score would be a 6 - Modified Independence if the patient is independent in all tasks (changing the bag, emptying the bag into the toilet etc.) The lowest would be a 1 – Total assistance if the helper completes all tasks.
Part 2: Frequency of Accidents - If the patient has no accidents, score part 1 only. If they have accidents, you determine the frequency and score accordingly.
The final score would be the lower of the 2 parts.
Are using the arms on an armchair considered to be an assistive device?
No. Chairs with arms are generally available in the community, so for the purpose of bed, chair and wheelchair transfers, they are not considered an assistive device. You would score a patient who transfers in and out of a chair with arms as a 7- Independent.
Can a patient score a 7 for transfers if using a wheelchair?
Yes. A wheelchair is not considered an assistive device for transfers. It is an assistive device for locomotion (as above)
If
the patient uses a mobile shower chair that they get into
in their room and then wheel into the toilet/shower do you
just assess the transfer into the shower chair even though
it is done in their room?
If a patient uses a mobile commode to access the toilet
and/or the shower they are scored
a 1 for that transfer as they are not considered to be transferring
onto the toilet or into the shower. If the patient is self propelling in the commode then score a 6.
If a patient has a colostomy bag and does not open his bowels? How do you score toilet transfers?
The patient is rated at level 1, Total Assistance, as the patient is not performing the activity.
The item toilet transfers included both voiding and bowel movements, so you would need to consider the amount of assistance the patient requires for both aspects and if the amount of assistance varies, record the lower score.
If a patient has renal failure and therefore does not create any urine and has no need to use the toilet? How do you score them in toilet transfers?
The patient is rated at level 7- The patient does not require any assistance with transferring on and off a standard toilet as he/ she does not use the toilet for voiding.
The item toilet transfers includes both voiding and bowel movements, so you would need to consider the amount of assistance the patient requires for both aspects and if the amount of assistance varies, record the lower score.
Can a patient score a 7 for locomotion if using a wheelchair?
No. If a patient uses a wheelchair for locomotion, the highest they can score is a 6, Modified Independence. A wheelchair is an assistive device for locomotion.
Is
signing an assistive device (as it depends on someone else
being able to sign)?
A sign language interpreter is treated the same as
an NESB interpreter, the patient is not scored down for the
use of an interpreter and can score 7 for comprehension and
expression if they are expressing complex and abstract ideas
with the use of an interpreter.
Are glasses considered an assistive device?
No. As adults, we predominantly use our auditory system to comprehend information. Glasses would only be considered an assistive device if required for lip reading and in this case would be scored as a 6, Modified Independence.
Is a hearing aid considered an assistive device?
Yes and would be scored as a 6, Modified Independence.
If a patient has to
use a pen and paper to communicate, is that classed as an
assistive device?
A pen and paper is not considered an assistive device,
therfore if a patient can express complex and abstract ideas
using a pen and paper they can score a 7 for expression, if able to express complex and abstract information in a timely manner. Score a 6 where the patient needs extra time.
* FIM and WeeFIM are trademarks of the Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc.
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