1. UNDERSTANDING THE FIM Functional Independent Measure Part 3

2. 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 Each FIM item MUST be scored every 24 hours

3. 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).

4. 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.

5. 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.

6. Patient asks to go to the bathroom How many FIM items could be addressed in this episode of care?

7. Possibly 12 Transfers: Bed, Chair, wheelchair Locomotion: Walk, wheelchair Transfers: Toilet Toileting Bladder Management Bowel Management Grooming Problem Solving Memory Expression Possibly Comprehension and Social Interaction

8. Toileting - Definition Includes maintaining perineal hygiene and adjusting clothing before and after using a toilet, commode, bedpan or urinal. The patient performs this activity safely.

9. Toileting Considerations If level of assistance for care differs between voiding and bowel movements, record the Lower Rating. Adjusting clothing: Moves gown out of the way and puts it back Pulls down and back up underwear, pants, shorts, pantyhose, etc

10. Toileting - Considerations Diapers & briefs are not articles of clothing and are not rated as part of this item. Diapers & briefs are assistive devices for bladder and bowel management

11. Toileting - Considerations Does not matter if a pt uses a toilet, commode, bedpan, or urinal Includes 3 toileting tasks Adjusting clothing before void or BM Perineal hygiene Adjusting clothing after void or BM

13. Toileting - Considerations Rate the patient only during a continent bladder or bowel episode Exception: Pt is always incontinent of both bowel and bladder and is therefore rated Level 1, Total Assistance

14. Toileting Considerations Rating for colostomy: Adjusting the clothing before and after emptying Cleansing/wiping the end of the bag after emptying DO NOT rate rinsing the appliance as this is part of bowel management

15. Bladder Management- Definition Includes complete and intentional control of the urinary bladder and, if necessary, use of equipment or agents for bladder control.

16. Bowel Management - Definition Includes complete and intentional control of the bowel and, if necessary, use of equipment or agents for bowel control.

17. B&B Function Modifiers An accident is defined as the act of soiling linen or clothing with urine or feces It includes bedpan and urinal spills as well as colostomy and Foley leakage It does NOT include stool or urine contained in a diaper (this is incontinence, not an accident)

18. Bowel Management Considerations Agents include: Stool softeners Suppositories Laxatives Enemas OTC (Senekot, Miralax, Metamucil) Does NOT include: Natural laxatives such as prunes, fiber cereal, herbal tea

19. 3 and 7 day look backs The bowel and bladder scores include accidents for 4 days prior to admission and the first three days on the unit. Therefore, it is imperative to include all incontinent episodes in the documentation.

20. B&B considerations Bladder equipment Foley catheter Urinal Bedpan Urostomy bag Bucket from bedside commode Absorbent pad Diapers Condom Catheter Bowel equipment Bedpan Colostomy bag Diapers Bucket from bedside commode

21. Note equipment choices in Medilinks on the next slide

23. Note choices for incidental assistance to place bedpan and resultant score on the next slide

28. B&B considerations If a patient receives hemodialysis or peritoneal dialysis and does not void, the patient will be rated a level 7 for bladder management – there is no burden of care

29. B&B considerations Standby assistance is usually for safety & should not be rated under B&B management Running water for a pt to void is NOT assistance Timed voiding program is NOT an assistive device

30. B&B considerations Timed voiding program Level of assistance is determined by how many times the pt remembers to call for assistance or goes to the bathroom independently If the patient is totally dependent on staff to implement the timed voiding this would be a level 1 level of assistance.

31. Timed voiding schedule Note choices for timed voiding schedule on the next slide

35. Bowel Management Level of Assistance Note a possible sequence of choices for patients requiring physical assistance on the next slide

41. Transfers - Definition Includes all aspects of transferring from supine in bed (not a mat) to a chair OR a bed (not a mat) to a wheelchair OR coming to a standing position if walking is the typical mode of locomotion.

42. Transfers – Considerations Based on overall performance, do NOT rate each skill or component of the transfer Consider the percentage of the ENTIRE task that the patient performs Bed, chair, and wheelchair transfers must begin OR end in a supine position from a BED (not a mat). Bed mobility IS included in the rating

43. Bed/chair/wheelchair - Transfers considerations If a patient transfers out of a wheelchair and the helper moves the wheelchair out of way for convenience of the staff member and then the helper needs to reposition the wheelchair back next to the bed for the patient, this is NOT counted as set-up. (If the patient was at home, the wheelchair would not have been moved.)

44. Assistive Devices Note in the next slide, the various types of assistance for transfers which may include bed rails, elevating the head of the bed or elevating the entire bed and the dropped score

46. 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