Frequently Asked Clinical Questions

 Frequently Asked Clinical Questions

Questions relating to:

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

Bladder and bowel management

 

 Transfers and locomotion

Bed, chair and wheelchair transfer

Toilet transfer

Walk/Wheelchair
 

 Cognition

Comprehension

Expression

Memory

 

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). However, if your team wants to record the functional gain achieved prior to the unexpected death, then enter a functional score for the patient that reflects their level of function at that point in time.

NOTE: Where the mode of episode end is recorded as ‘death’, AROC considers the episode ‘incomplete’, that is the person did not complete their rehab program. Incomplete episodes are not included in outcomes analysis.

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 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 to 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
* 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). Where the mode of episode end is recorded as ‘transferred to acute care’, AROC considers the episode ‘incomplete’, that is the person did not complete their rehab program. Incomplete episodes are not included in outcomes analysis.

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 Are FIM™ assessment dates essential?
Function is assessed using the FIM instrument at admission and discharge. The timing of the admission scoring is important because clinically, a person’s functional capacity changes upon commencement of a program of rehabilitation. To achieve an accurate base measure it is important that the initial measurement is done in a timely manner. Similarly, it is important that the discharge assessment is done within a time frame that allows the total functional improvement of the patient to be measured. To measure the timeliness of scoring on admission and discharge the AROC data set requires the collection of the date on which each of these scores was achieved. It should also be noted that timeliness of functional assessment on admission and discharge is an ACHS Rehabilitation Medicine clinical indicator.

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 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 patient'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."

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 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 i.e. 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.

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 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.

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 Are dentures considered an assistive device?
No. If someone eats with dentures in, they can still score a 7, Independent.

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 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.

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 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.

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 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.

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 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.

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 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.

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 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.

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 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.

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 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.

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How do you score a client if they can perform all showering tasks, however during periods of depression they require prompting to initiate to take a shower?
If the patient requires prompting due to depression, score 5.

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 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.

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 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 definition for toileting and can score a 7 for that also.

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If a patient uses their prosthesis during the process of getting clothes from the drawer (not for actual dressing), is it considered an assistive device? 
Yes, the definition of lower body dressing includes getting the clothes from where they are stored, so if prosthesis is used to assist with this part of the activity, it should be considered as an assistive device.

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 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.

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 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.

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 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.

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 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 i.e. 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.

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 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.

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 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.

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 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.

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 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.

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How do you score a patient who is incontinent, but does not "soil clothing or bedclothes" as per the definition in the manual? For example, a patient who is unable to control his bladder or bowel and is incontinent when walking (naked) to the toilet in the bathroom, or a patient who is incontinent when naked in a hoist sling, or naked sitting on a commode on the way to the toilet?
In this situation it is most clinically relevant to consider whether the patient has control of their urinary or anal sphincter or not. Strictly speaking the patient would not be scored down in Part 2, Frequency of Accidents for opening bowels or bladder unless clothing etc. is soiled. In the very specific scenario given above it is clear the patient does not have sphincter control. The patient does not soil clothing as they are not wearing any, but equally, they do not have control over their bowels AND there is a burden of care in the clean up. It would be reasonable to include these incidents in considerating the Frequency of Accidents (Part2) scoring, and the lower score between Part 1 and part 2 of the item would apply.

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How do you score a patient who has bowel control, but chooses to open their bowels in inappropriate places e.g. in a bin, pot plant?
This patient is clearly not having an "accident" as they are choosing to open their bowel in an inappropriate place. Thus it is clear they have control over their bowel and then the scoring of Part 1, Need for Assistance would reflect this. Clinically these patients may benefit from supervision, cueing or coaxing etc. and so score of 5 may be appropriate. If hands on assistance is required, a score of 4 or less should be recorded. Consider this scenario when scoring the cognitive items for this patient.

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 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. 

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 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)

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Is there a "hierarchy of aid" consideration in FIM?
No, there is not. If the patient is using a frame to mobilise at least 50 meters independently on admission and progresses to using a stick  to mobilise at least 50 meters on discharge, they would be 6 on admission and discharge - despite the "hierarchy of aid" going up a few notches.

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If a patient wears an orthotic (platform shoe) on his right foot due to a discrepancy in leg length and he is able to mobilise 50 meters, independently and safely, what would their FIM score be?
They would score a 6, modified independence as modified shoes are considered an assistive device for locomotion.

What is the FIM score for a visually impaired patient who is able to mobilise 1km with their guide dog?
Their FIM score would be a 6, modified independence as a guide dog is an assistive device for locomotion.

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 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.

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 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.

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 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.

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 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.

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 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.

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 Is a hearing aid considered an assistive device?
Yes and would be scored as a 6, Modified Independence.

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If someone has severe receptive dysphasia, it will have a significant impact on the assessment of memory. Is there anything that can be done except score as you see it?
A patient's communication impairment may affect their ability to perform some of the cognitive items, and clinicians should score all items as the patient performs them over a 24 hour period. In the case of dysphasia, the patients ability to "store and retrieve information, particularly verbal or visual" (as found in the definition for memory) may be affected, and as you say the patient should be scored for memory regardless of the cause for less than independent performance.

It  would also be helpful to discuss the patient's functional performance rather than solely using the patient's expression as an indication of their ability to comprehend.

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If glasses are worn as an assistive device for comprehension (person’s primary mode of comprehension is visual), is the actual assistance required to put them on and take them off rated in the FIM?
Yes, the physical act of putting on glasses that are considered an assistive device for comprehension, would be considered 5, set-up.

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 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, therefore 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.

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If a patient is in PTA, do they automatically score 1's for all of the cognitive items?
No, you still assess the client's ACTUAL PERFORMANCE despite them being in Post Traumatic Amnesia (PTA). The amnesia is an impairment which is most likely impacting on their ability to carry out daily tasks, however the FIM assesses the type and amount of assistance required to complete a defined set of daily tasks. So, continue to assess your client's functional performance despite them being in PTA. You may find that they get low scores for the items memory, problem solving and social interaction as the amnesia would impact on their ability to carry out daily tasks. The communication items may or may not be low for the same reason... If the scores are low, it's because of their ACTUAL FUNCTIONAL PERFORMANCE and not just because they are in PTA.

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Last reviewed: 9 December, 2014