Frequently asked questions

Eligibility

Who is eligible to do the exam?

The FIM / WeeFIM tool is non-discipline specific therefore anyone who has tertiary level clinical training (medicine, nursing, allied health) can become credentialed. Refer to the Training and Credentialing page for more details.

Access exams and training

How do I obtain exams and/or other resources?

Information on obtaining exams is available on the Training and Credentialing page. Information on other resources is available on the Resources page.

How do I obtain training?

There are a few different ways to obtain training. Further information can be viewed on the Training and Credentialing page. In summary:

• AROC conducts workshops that are open to anyone interested in being trained, as long as they are clinically trained (medical, nursing, allied health). Workshops are conducted at least once a year in major centres around Australia and New Zealand.
• If there are a significant number of people who require training from your rehab facility, your facility may wish to Invite an AROC Master Trainer to come to your site to conduct a workshop.
• If there is a Facility Trainer at your facility, you may request training from them. AROC supports Facility Trainers to organise workshops by sending resources and exams when purchased.

Exam results

What happens if I fail the exam?

Your exam key provides for three chances to pass the exam before it expires. Note, if you are a new user of the FIM or WeeFIM instrument you are required to attend a  before attempting the exam. It is also wise to study the manual before attempting the exam. Remember, it is an open book exam, so you should have your manual with you when you attempt it. AROC (or your Facility Trainer) can also provide you with some case studies to practise before you attempt the exam.

How long should I expect to wait for my exam result and certificate?

You will receive your results immediately once you submit the exam. Results are sent via email. If you pass, your certificate will be available for you to download immediately. You can download your certificate as per below:

After logging into AOS with your FIM ID, under the FIM menu enter into My Exam Keys

1. Under “My Completed keys”, click GO TO CERTIFICATE for the Certificate date you require
2. Click MY ACTIVITIES then click FIM Qualification
3. Scroll down to FIM Certificate and click on “FIM Certificate Complete”
4. Select “Get your certificate”

Credentialing

How often is a credentialed clinician required to re-credential?

A credentialed clinician is required to  every two years. 

Re-credentialing is dependent on two things; If your accreditation has expired, and when you last attended a FIM workshop.

Currently credentialed

• If you have attended a workshop within the past 2 years and your accreditation is about to expire, you can simply purchase an Exam to re-gain your accreditation.
• If it has been between 2 and 4 years since you attended a workshop and your accreditation is about to expire, you can purchase an Online Refresher (includes an Exam) to re-gain your accreditation.

Expired credentialing

• If you have attended a workshop in the past 4 years and your accreditation has expired:
  • Less than 12 months - complete the Online Refresher with examination
  • Longer than 12 months - attend a face to face FIM workshop and complete the examination

If you have not attended a workshop within the past 4 years – you will need to do so to re-credential.

How can I check my credentialing?

The date when your credentialing expires is shown on your credentialing certificate. Alternatively, after logging into AOS with your FIM ID, click My Details to view your accreditation.

* FIM and WeeFIM are trademarks of the Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc.

FIM and Facility Trainers

Who should I contact if I have a clinical question regarding the FIM instrument?

Contact FIM 

How much does it cost me to purchase an examination?

Examinations are charged at a fee of $41.00 + GST. All resources and their costs can be viewed on the Resources page.

How do I become a Facility Trainer?

Details of how to become a Facility Trainer can be viewed on the Training and Credentialing page.

General scoring

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 person 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.

Can you explain Scoring on Admission?

Operationally, in order for a rehab team to capture the TOTAL functional gain achieved during a rehabilitation program, AROC trains our member services to score the FIM as soon as possible after admission to establish an appropriate baseline score. Then score the FIM again as close as possible to discharge to reflect the functional status of the person at discharge. ACHS and MeTEOR, because of what they are, need to put a timeframe in their definitions. However, operationally, a service should not wait 72 hours before scoring FIM, as they will then miss capturing any functional gain that happens in the first few days. This is summarised on our website here

A person was discharged and the FIM scores had been completed. While they were waiting to be transported home, their condition deteriorated and were transferred to an acute hospital. Should the FIM scores reflect their condition at the time of discharge or when they actually left our facility?

We use FIM data to measure functional change achieved within a rehabilitation episode. This person’s score should reflect the functional change achieved prior to the next episode starting. The FIM score should therefore reflect their functional ability at the time of discharge and not when they left the facility. You would need to make a comment in the AROC dataset that their mode of episode end was "transferred to another hospital as condition deteriorated post discharge."

What is the age range that the FIM can be used for?

FIM must be used for patients 18 or older.  WeeFIM must be used for patients up to 8 years old because age norms apply. For patients between the ages of 8 to 18, no age norms apply and FIM or WeeFIM can be used. This generally depends on the team treating the person. The FIM is often used if the person is treated by an ‘Adult’ rehab team and WeeFIM if they are under a Paeds team.

Can someone who is not FIM trained complete parts of the assessment under the guidance of a FIM trained practitioner? For example, can a physiotherapist fill in mobility sections if reviewed by someone who is FIM trained?

The non-FIM trained practitioner should document their assessment/observations in the person’s file. A FIM credentialed practitioner may access this information in support of their assessment/observation of the person’s ability when scoring the FIM.

Could you provide some guidance in relation to the use of FIM and manual handling risk, given requirement of minimal to maximum assistance?

When scoring the Transfer, Locomotion and Stairs Items for FIM we recommend that “Clinicians should pay due reference to their states/services lifting policies”. Most Moving and Handling Policies state a clinician should never take more of another person’s weight than they are taking themselves. Therefore a FIM score of 2 (maximal assistance) for these items would not be used in the inpatient setting.   FIM is used for both inpatient and community settings. As the score is based on the actual performance of the person being assessed in the community, the score of 2 may reflect the actual performance therefore it remains a possible score for these FIM Items.

For the inpatient setting the general rules for these items are as follows:

Score of 4 - Minimal assistance: there is some hands on touching, contact guarding or steadying assistance given – the helper does not take any of the person’s weight.

Score of 3 - Moderate assistance: the helper takes some of the person’s weight in the task however, the person must be taking more of their own weight than the helper is taking.

Score of 2 - Maximal assistance: is not likely to be able to be used in the inpatient setting due to Patient Moving and Handling Policies in this setting.

Score of 1 - Total assistance: 2 helpers are required and/or a hoist or another mechanical device is used to move the person or the person is bedridden.

Can you please email me the current FIM Assessment recording sheet?

Apart from the sheet used for Admission and Discharge FIM Scores as part of the AROC Data Collection Proforma, AROC does not have a FIM Assessment recording sheet. There is a basic example of one in the FIM Facility Trainers Manual to use with the practice case studies during FIM Workshops. Some facilities develop their own or just use the Data Collection one. Practice varies as facilities develop processes to suit their own systems.

Can a facility use FIM for day patients?

The AROC dataset requires the collection of FIM for the inpatient dataset, however, for rehabilitation in an ambulatory setting and the ambulatory data set AROC does not collect FIM. FIM is an ADL (Activities of Daily Living) tool and measures basic ADL tasks. An individual in an ambulatory setting is generally functionally able to undertake these basic tasks to a significant degree, and thus FIM tends to demonstrate a ceiling effect when used in an ambulatory setting.

In an ambulatory setting it is more common to use an IADL (Instrumental Activities of Daily Living).  In the AROC ambulatory dataset, the main outcome measure is The Australian Modified Lawton’s IADL scale. There are also impairment specific outcome measures used for stroke, orthopaedic, reconditioning and brain injury. Information regarding the ambulatory dataset and outcome measures can be found on the AROC website on the ambulatory dataset page. The ambulatory data dictionary and the data collection forms will also provide you with further information about the ambulatory dataset.

What should the FIM score be for a person with a brain injury who requires constant 24/7 companion care to keep them safe? Should they automatically be scored 1 on all 18 items?

No, they are not scored 1 automatically.

For the motor items, they could score 5’s (Supervision) depending on person’s ability. For example, if they can dress themselves independently, however, are supervised for all activities due to their brain injury, the score for dressing would be 5 – Supervision. If the person can transfer from a bed to a chair, but requires contact guarding and supervision during the transfer, the score would be 4.

Communication items could score at any of the levels depending on the person’s ability. To score Comprehension, you need to ask whether they are able to understand complex and abstract information. If they cannot, you need to ask whether they are able to understand basic information (i.e. eat your meal, or put on this cardigan) without any other input. They could score a 5; the amount of prompts required will determine any lower score. For Expression, the score will depend on their ability/need for prompts. The companion being there would not necessarily impact on the score of these 2 items unless they have to prompt.

For the cognitive items you need to identify whether the constant companion is required due to memory issues, problem solving issues, behaviour issues or all of them? As a constant companion is a form of restraint, you need to identify whether they are required because of behaviour issues – Social Interaction or lack of insight and poor decision making – Problem Solving. It may be for one or both reasons and as it is constant the score would be a 1 for those items. If the companion is required due to memory impairment, the Memory item would also score a 1.

If a person needed a helper to do 50% of the task, but needed prompting for the other 50% do they score a 3? As the person completed 50% after setup/prompting. Or do they score lower as the helper needed to provide setup/be present for all elements of the task listed in the definition.

It would be a score of 3, especially if it is for motor items, as the person is doing 50% of the task. However, they would more than likely score no higher than a 3 in some of the cognitive items if requiring that amount of prompting. You would have to ask “did they require that amount of prompting due to comprehension issues, problem solving, memory or even lack of motivation (Social Interaction) or a combination of the cognitive items” and score appropriately.

My understanding is FIM is scored on admission and discharge utilising a 24 hour picture of all assistance provided in this time frame. Can you please confirm that in public health they do not require further FIM scores to be done other than on admission and discharge?

In terms of AROC policy for our data collection requirements, we require the FIM to be completed on admission and discharge only; however we are aware of some facilities that choose to collect ‘progress’ FIM scores at different time points during an admission (e.g. brain and spine patients with longer lengths of stay).

Unfortunately we are unable to advise regarding state public health requirements.

If my credentials have expired, am I still able to score FIM for patients whilst waiting for re-credentialing? Or do I need to re-sit an exam before I can continue to score the FIM?

Any clinician scoring/using the FIM instrument must have current accreditation.

Is it correct that you can pre-emptively FIM score a person on admission and go back and change the score after 24 hours?

The recommendation is the FIM score (the entire 18 items) is completed 24 hours after admission to an inpatient rehabilitation facility to reflect the patients functional abilities at that point in time.

A FIM score should not be changed unless it is incorrect (document change should be done as per unit’s documentation change policy) and not because the person’s ability has changed.

Another FIM score (the entire 18 items) can be done at any time. This does not change the initial Admission FIM Score, but is known as an Interim FIM Score.

If a person was admitted to the rehabilitation ward and they self discharged the following day do we still complete admission and discharge FIM scores?

Complete initial FIM scores as well as you can based on observations of the staff while the person was there. The discharge FIM score will be the same as the admission score. As the person self discharged this episode will be considered incomplete by AROC and not included in outcome analysis (LOS and FIM change) for your reports, but will still be counted as an episode of care.

Eating

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 person would be scored a 5 or less.

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.

Are dentures considered an assistive device?

No. If someone eats with dentures in, they can still score a 7, Independent.

Is meal preparation assessed in FIM?

No. The Eating item relates to the meal placed in front of the person on a table or tray. Meal preparation is not assessed in FIM.

If when at home someone butters their toast before it is presented to them on the table, is it considered set up? As opposed to a person in hospital who needs a helper to butter their toast as they get the butter packet placed in front of them on the table?

Did the person require any assistance once the meal was placed in front of them? Score only on the assistance that is required at that time once the meal is placed in front of the person. FIM score is not compared to what was given in a different environment i.e. the inpatient setting vs the home setting. This situation might be a good opportunity to provide some rehab education to the helper and the person by encouraging the helper to let the person be more independent by having ‘a go’ at doing it for themselves.

If someone is has their fluids thickened prior to it being presented to them is this considered setup?

No. If fluids are thickened prior to being presented to the person this would be considered part of the meal preparation and hence not affect their score.

Thickened fluids are considered a ‘modification’ to the diet so the score would start at a 6.

How do you score a person whose food is cut up by kitchen staff before being presented to the person? 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 person 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 person does not require food cut up for safety or require a modified diet, you would score a 7, independent.

When a helper cuts up the person’s food, pours sauce or dressing on food, is the person rated level 5?

Yes. Score level 5 setup was required.

If a meal is cut up for someone due to their tremor to prevent food going everywhere is that modified independence and scored a 6?

If the food is cut up for a person for any reason, the score is a 5. 

Ask the question: “Does anyone need to be in the room for the person to carry out the task?”

If the answer is no, they can score a 6 or 7.

If the answer is yes, as in this case (someone needs to be there to cut up the food), the score can be no higher than a 5.

If a person requests a modified texture diet, as they prefer this type of food texture, how is this scored?

In this situation, consider whether the person requires the modified texture diet, that is whether it is clinically indicated, or whether this is a request based on personal preference. If the person is requesting a modified texture diet due to personal preference, but is assessed by the Speech Pathologist as being able to swallow a standard diet, you would score the FIM item: Eating as a level 7: Complete Independence. However, if the person required the modified texture diet to be deemed safe when eating then score level 6: Modified Independence.

For eating, what is the difference between scoring a 2 “helper assists by guiding hand to scoop food, bringing food to mouth and placing food in mouth" and a 1 "Helper guides person’s hand through all movements"?

The helper can guide the hand through various parts of the task, but the key point is the person must have effective input for at least 25% of the overall task to score a 2.

The score of 1 is given when the person is doing less than 25% of the overall eating task. The key difference between the two scores is the percentage of the task the person is doing.

If someone consumes a supplement that is not prescribed to them, is this considered level 6? Or does it have to be a specialised dietitian prescribed supplement?

Supplements are not considered in the scoring of Eating item. However, if the person is having a regular dietician input; i.e. food diaries checks and regular weighs by a dietician, then this is considered ‘Supervision’.

What is the difference between adult FIM and WeeFIM PEG scoring?

FIM: If a person has a PEG, JPEG or NG feeding tube in situ to receive all or part of their nutritional needs, the FIM score is based on the amount of assistance required to administer the enteral feeds. Note the score cannot be higher than a 6 as these are all considered modifications.   

WeeFIM: Any tube feeding in children is usually scored 1. Children do not usually do any of the task themselves; therefore, it is a high level of burden. For example, if a helper administers the food with no input from the person, the FIM/WeeFIM Score is 1. If the person is able to administer the food themselves, with instructions and supervision, the FIM/WeeFIM Score is 5. This does NOT include TPN.

Grooming

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.

If someone needs to sit on a chair to undertake their grooming, is the chair or wheelchair considered to be equipment, thereby scoring a level 6?

The person can still be a 7. Sitting down does not reduce the score.

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?

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 person who refuses to brush their teeth as part of grooming and is independent in washing their hands and face with prompting.

They are independent with teeth as they require no assistance, they require supervision for face and hands therefore score a 5.

What would be the score if a helper is needed to support the arm in order for a person to complete grooming tasks?

The person would not be able to complete the tasks without a helper, therefore the score would be a 1 – total assistance.  If the person could do one of the tasks but not the other two without the helper, then they would score a score of 2.

Many women shave their legs second daily and Millennials shave many different body parts all the time. Should these be included in grooming?

FIM is a minimum dataset. This FIM item clearly states that it is shaving of the face. Despite other areas of the body often needing shaving this is not relevant to the grooming item in FIM.

Refer to the FIM manual FIM Item Grooming definition.

Bathing

Is a shower chair or stool deemed an assistive device during bathing?

No. The item bathing refers to the person’s ability to wash, rinse and dry their body from the neck down. It does not matter if they are 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?

Hans-held showers are considered assistive devices IF they are required to wash, rinse and dry the body ie: If the handheld shower were not available, the person would need assistance from a helper.

How do you score a person 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 person is using the armrest to lift their body to wash, rinse, and dry their bottom.

If someone uses a rail to shower is that scored 6 in Shower Transfer or Bathing or both?

This depends on whether it is used to assist with bathing (i.e. holds the rail while washing, rinsing or drying) or simply for the transfer into the shower.

If it is not required to assist with any of the bathing task, then it is only scored in the transfer.

How do you score a person who can normally shower independently, however during periods of depression they require prompting to initiate to take a shower?

The FIM is scored over a 24 hour period. Score based on the previous 24 hours period. If the person requires prompting during that time due to depression, score 5, if not score 7.

The body is divided into 10 areas but what if the person can do part but not all of the area e.g. can do their lower leg but not foot?

Bathing includes washing, rinsing and dry. The person needs to complete the whole area e.g. lower leg and foot to score. There are no half or part scores. The area has to be completed in its entirety to score.

Why is the back not included in bathing? Does this mean that a person who independently showers but needs assistance with washing their back scores a 7?

Yes, the FIM does not measure back-washing.

Most people do not wash their backs as they would other body parts. For example, they wash their back by lying in the bath or let the water run down their back in the shower, therefore it is not included in the FIM.

Bathing includes washing, rinsing and dying. Is air-drying acceptable?

Yes, within reason. FIM does not score on the quality of performing the task, but on the need for assistance or burden on care.

Night staff do not view showering, dressing etc. Can they leave these FIM spaces blank?

All FIM Items must be scored.

Are the night staff not viewing patients showering or dressing due to the patients showering or dressing on another shift or the patients are showering and dressing independently and not viewed?

If they are not viewed due to independence then the score would be a 6 or 7 as they require no assistance – they could be asked if they held a rail etc. and this information is valid for documenting.

If it is due to showering and dressing on another shift, then the information for scoring, like all the information for scoring FIM, should be in the progress notes of the person.

If this issue is due to in-house forms, i.e. tick boxes for the shift, then this is the downside of using this type of documentation rather than expecting clinicians to write informative concise documentation in the person’s progress notes. Tick boxes rarely provide detailed descriptions of the type of and exactly how much assistance a person needs therefore making correct auditing difficult.

Dressing - Upper Body

When scoring upper body dressing, I note that the definition refers to both dressing and undressing. Do I score dressing and undressing separately and then take the lowest score?

No, the FIM item ‘upper body dressing’ states that it ‘includes dressing and undressing above the waist’ and therefore both aspects must be taken into account when scoring this item.

You do not score dressing and undressing separately and take the lowest score, but rather you first calculate the total number of steps included in both dressing and undressing, then determine the steps that are completed by the person and those completed by the helper. The FIM score will reflect the proportion of steps completed by the person. Note: The same principle applies for the lower body dressing item.

How do you score a spinal person 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.

If on admission, a person is wearing loose fitting clothes and less layers, is it fair to conduct the discharge assessment (quite a long time later), when they are wearing tighter fitting clothes and more layers?

The Dressing FIM scores are based on what the person is actually wearing in the 24 hour period of FIM scoring and how much help they require to put on and remove any clothing in that period of time. The FIM is not concerned about what they wore at any other time.

If someone doesn’t wear a bra as they can’t do it up, do you include it as an item? That is, they usually wear a bra, but due to a stroke aren’t at the moment and have declined having a helper put one on them.

Dressing is scored on the amount of assistance required for the items of clothing a person are actually wearing. If they are not wearing a bra this is not included.

What does Jenny score? Jenny wears a bra and t-shirt. When dressing, Jenny threads both bra straps and a helper fastens the bra. Jenny then threads her right and left arms into the t-shirt and the helper lifts the t-shirt over her head and pulls it down. When undressing, the helper pulls the t-shirt up Jenny’s trunk and lifts it over her head. Jenny then pulls the t-shirt off her right and left arms. The helper unclasps Jenny’s bra, and then Jenny unthreads both bra straps from her arms.

This is a total of 14 steps. Jenny completes 8 of the 14 steps (i.e. threading two bra straps, threading two arms into t-shirt sleeves, unthreading arms from t-shirt sleeves and unthreading bra straps), and therefore this equates to 57%, a FIM score of 3.

Dressing - Lower Body

How do you score a person who does not wear any underwear for dressing lower body? The person did wear underwear prior to their hospital admission. They independently dress the rest of their lower body?

Lower body dressing is concerned with dressing and undressing below the waist. Underwear does not need to be worn. If they independently dress below the waist they score 7. If not wearing underwear led them to expose themselves this would affect their score for social interaction and problem solving.

If a person chooses not to wear shoes, do we include shoes or not as it is not considered socially appropriate to not wear shoes?

FIM is only based on the help a person requires, therefore, if they do not wear shoes then shoes are not included. If it is socially inappropriate to be barefoot (remember it is about general standards not our own), then this would impact on the Social Interaction FIM score i.e. attended a job interview barefoot. If it is required to wear shoes for safety reasons, i.e. as per PT instructions, then this would impact on the Problem Solving FIM score.

If a person 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.

If a person wears hip protectors to reduce the risk of injury if they fall, should they be included as clothing when scoring dressing or are they considered prosthesis/orthosis like TED stockings?

Any special garment worn for a medical reason fits into the orthotic group and despite the difficulty scores a 5.

If a person wear pull up pads instead of underwear are they scored as an item of clothing for the purposes of lower body dressing? Or only considered for bladder/bowel management?

Continence products are scored only in the Bladder or Bowel Items and the highest score that can be achieved is 6. Continence products are not underwear. FIM does not stipulate a person must wear underwear for dressing.

Would adjusting underwear only score 5 for lower dressing?

No. As soon as any part of the clothing is touched the score is no higher than a 4. For a score of 5 you cannot touch the person or the clothing – ‘Supervision/Set-up’ only.

Toileting

What is the score for a person who has an IDC and colostomy and does not use the toilet?

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 person 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 item toileting includes both voiding and bowel movements, so you would need to consider the amount of assistance the person requires for both aspects and if the amount of assistance varies, record the lower score.

For voiding the person is rated at level 7- they do not require any assistance with toileting as they don’t void.

When considering "ability to adjust clothing before and after using toilet or bedpan" do we consider ability to adjust the hip protectors/pull-ups?

The continence products are not clothing, so not considered when scoring this item. Score based on the other items needing adjustment.

A person is having multiple accidents (almost daily) and having full assistance with managing their pads. They are, however, requesting a bedpan regularly throughout the day to minimise their accidents. How should they be scored?

Part 1: Due to the requirement of total assistance to manage the pads the Part 1 score is a 1.

Part 2: The person is attempting to reduce their accidents score is 2.

The lower score of the parts will be the Bladder Item Score, i.e 1.

How do you score a person that reports they have been to the toilet but you haven’t seen them?

FIM is about ‘burden of care’. If the person has not required any assistance during the Toileting and Bladder and/or Bowel tasks you would have to go with information they gave you. You would enquire though if they used any assistive devices e.g. rail to decide between a score of 6 or 7. If they went independently and there were issues, you may also have to consider the scoring of the cognitive items.

Is a bidet considered an assistive device for toileting when it is used for cleaning the perineal area and is the only way this can be done?

Yes – if a bidet is used it is considered an assistive device for the Toileting Item.

If a person is using the toilet during the day, but uses a bed pan or a commode chair overnight, do they score 1?

The bedpan needs to be considered in the scoring of Bladder or Bowel depending on what it is used for.

The commode chair, if mobile and mobilised over the standard toilet, is scored in the Toilet Transfer depending on the amount of assistance required.

If the commode is stationary at the bedside, it is a Bed to Chair Transfer and the person would score 1 for the Toilet Transfer as they are unable to transfer on and off a standard toilet. The ‘rehab’ question to ask here is; ‘why can they not use a standard toilet overnight if they can use it during the day?’

Facility trainers see also Bladder/Bowel Tip sheet available in AOS.

Bladder management

How do your score a person who wets the toilet seat or floor?

If the person does not contain their urine and has a bladder spill onto the floor, consider the assistance to clean up the urine under Bladder Management. If the person only wets the toilet seat, do not consider it a urine spill.

How do you score a person that is using incontinence pads?

A person who wears incontinence pads can score a 6 if the pads never leak onto their clothing/bed clothes and if that person manages the pads independently i.e. changes them themselves.

The person is only classed as having accidents or being incontinent if their clothing or bed clothes are being soiled/wet.

Bowel 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 person has a colostomy bag and therefore does not open their 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 person needs with managing the colostomy bag. The highest they could score would be a 6 - Modified Independence if the person 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 person 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.

How do I score if a person has regular (second day/weekly) but not daily enema/suppositories?

Even though the enema/suppository is not given daily, it has a regular and constant effect on the bowel function and therefore needs to be considered when scoring FIM. Score the level of assistance required for the person to complete the task regardless of the frequency, as long as it is given regularly.

If the enema/suppository is intermittent then only consider it in FIM scoring if it falls on the FIM day. If it falls on the FIM day then highest score for the level of assistance required would be 6. 

How do you score a person who has bowel control, but chooses to open their bowels in inappropriate places e.g. in a bin, pot plant?

This person 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 person.

Bladder and bowel management

If someone has been prescribed a medication for prostate condition (not necessarily urgency), is this a level 6?

If the medication is prescribed for a prostate condition, it is not relevant to the Bladder Item.

How do you score a person who is incontinent, but does not "soil clothing or bedclothes"? For example, a person who is unable to control their bladder or bowel and is incontinent when naked sitting on a commode on the way to the toilet?

In this situation it is most clinically relevant to consider whether the person has control of their urinary or anal sphincter or not.

In the very specific scenario given above it is clear the person does not have sphincter control. The person 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 considering the Frequency of Accidents (Part2) scoring, and the lower score between Part 1 and part 2 of the item would apply.

If a person has had one single episode of bowel incontinence since a head injury in the past 6 months would this be included in scoring?

We do not look back 6 months for FIM Scoring purposes. Regardless of whether the FIM is scored for the purpose of a ‘one-off/snap-shot’ assessment or as an outcome measure (at 2 points of time), FIM is scored on the need for assistance of the person for previous 24 hour period only. That rule applies for all of the items, except for the Bladder and Bowel items as they include the ‘accidents’ that have occurred within the previous 72 hours (or three days) prior to assessment.

Bed, chair and wheelchair transfer

Can a person 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.

Is 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 person who transfers in and out of a chair with arms as a 7- Independent.

Is a walking aid considered an assistive device if they use it to transfer from the bed to the chair?

Yes, any aid used to assist in getting from a bed to a chair and back is included.

This transfer is only about being able to get from a bed to a chair or a wheelchair that is beside that bed.

How should the use of steady sara equipment for the purposes of transfers be scored?

The majority of the time, as there is a no lift policy and 2 staff are used, it is scored a 1. Sometimes on discharge or transferring in the community, it could be scored a 2. Score to be determined by how much of the activity the patient/client performs.

A patient can only transfer/walk if they wear a helmet. I understand that a helmet is not included with the Dressing Upper Body item, is it included with the Transfer or Locomotion items?

A helmet is a medical device. For the purposes of scoring FIM it is not counted.

Toilet transfer

If a person has an indwelling catheter, but still use the toilet to open their bowels, do we score their ability to transfer on the toilet for those times (and disregard that they don’t use the toilet to urinate)?

The Toilet Transfer does not stipulate whether the toilet is used for bladder or bowel. Toilet FIM Score is based on the person’s ability and the amount of assistance required for them to get on and off the toilet. This applies to for bladder or bowel or both.

A person has both a colostomy bag and permanent IDC. To manage their stoma and IDC they sit in a chair and therefore do not transfer on/off the toilet. What I should score them for toilet transfers? They have the ability to complete toilet transfers independently.

You would score 7. The reasoning behind that score is that it is about the person's ability getting on and off a standard toilet (regardless of their need to use one or not) and they are scored on the level of assistance they require.

If the person uses a mobile shower chair that they get into in their room and then are wheeled into the toilet/shower, do you just assess the transfer into the shower chair even though it is done in their room?

If a person uses a mobile commode and is wheeled by a helper 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 person is self-propelling in the commode then score 6 , supervised/prompted score a 5, a little help positioning score a 4, more help but doing more than the helper score a 3, significant help but some effective input score a 2 and pushed by helper a 1. The transfer in the room is scored as the chair/bed/wheelchair transfer. 

A person is hoisted onto a self-propelled commode which they independently push over the toilet. Do we consider the amount of assistance required for the person to get onto the mobile commode?

If the transfer happens anywhere other than inside the doorway of the toilet or shower the "significant burden of care" is actually in the 'Bed to Chair Transfer' and the ‘Toilet and Shower Transfers’ are scores of 6 - Modified Independence (using an aid independently). There is no burden of care once inside the toilet or shower for the transfer.

Bath or shower transfer

If someone can both shower needing rails or bath requiring help to get out, which do you score them for transfers?

The FIM Scoring is based on the person’s ability during the previous 24 hours, therefore it would usually be either the bath or the shower not both. However, if for some reason in that 24 hour period they did use both, you would score the greatest need for assistance of the two, which in this case would be the bath.

Is a shower chair seen as a 'special seat' in bath transfers?

Normally, there is no seat in either a bath or a shower, therefore, if one is used it is considered an assistive device for shower or bath transfer. Score of 6, unless it needs setting up, then becomes a score of 5.

Facility trainers see also Household Ambulation Tip sheet available in AOS.

Walk / wheelchair

Can a person score a 7 for locomotion if using a wheelchair?

No. If a person uses a wheelchair for locomotion, the highest they can score is a 6, Modified Independence. A wheelchair is an assistive device for locomotion.

Is there a "hierarchy of aid" consideration in FIM?

No, there is not. If the person 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.

If a person wears an orthotic (platform shoe) on their right foot due to a discrepancy in leg length and 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 person 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.

If a person is able to ambulate 10m then rest on a chair, walk a further 20m then rest on a chair and then walk a further 10m is this classified as being able to ambulate 50m?

Locomotion score is based on the distance mobilised without a break. If the person can only manage to walk 10 meters then rest, 10 meters is the distance mobilised. This being less than 17 meters results in a score of 1.

"The rehab team anticipate that a person will use the wheelchair on discharge. On admission to the rehabilitation ward the person travels 50m by themselves; although they are a little unsafe - bumping into things!” How do you score it?

The score would be a 6 – independent with safety concerns. The admission and discharge scores are on person’s ability to use the wheelchair – remembering the use of a wheelchair can only achieve the highest score of 6 as wheelchair used for locomotion counts as an assistive device.

How do you score Locomotion Mode on discharge?

The expected discharge mode is the same mode that you scored on admission. For example, if a person is admitted to rehab in a wheelchair, but it is expected that they will be walking when discharged, then score them on their ability to walk at admission. GRAPHIC

What is the scoring principle for using a knee scooter?

The scoring principle for using a knee scooter (where the person is not completely wheeling or walking) is deemed as walking with a mobility aid.

My hospital has a policy stating that everyone admitted to hospital needs to be at minimum ‘Stand-by assist’ for transfers and mobility for the first 48hours. Should we be scoring the patients actual performance or the burden of care that the hospital has caused due to the policy?

For accuracy of data, a qualified FIM clinician needs to ask the question “does the person need the supervision or are they just supervised due to the blanket policy of the facility”, and then score appropriately based on what the person actually needs.

Stairs

If a person is assessed by the physio as independent on 12 stairs with a handrail on the first day of admission but then doesn’t complete stairs at any other time in the first few days, what would they score?

If the physio assesses the stairs and deems a person clinically safe to ascend and descend at least 12 stairs with the use of a rail then the score would be 6.

As the physio is with the person whilst doing the stairs the assessment does count as supervision?

The physio must assess whether supervision is required for the person to complete the stairs. Simply being there for the assessment does not count as supervision.

If someone does stairs on their bottom safely and timely what do they score?

They would score 7.

Do you need a staircase of 12+ stairs to complete the stairs assessment?

No. Most hospital gyms will have sets of three-four stairs, completing these multiple times (e.g. up and down four steps three times) to add up to 12 without a rest is sufficient for complete the FIM stairs assessment.

Facility trainers see also Cognition Tip sheet available in AOS.

Comprehension

Does the use of an interpreter alter scoring?

No, it has no impact on scoring.

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 person 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 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.

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 person’s communication impairment may affect their ability to perform some of the cognitive items, and clinicians should score all items as the person performs them over a 24 hour period. In the case of dysphasia, the person’s ability to "store and retrieve information, particularly verbal or visual" (as found in the definition for memory) may be affected, and the person should be scored for memory regardless of the cause for less than independent performance.

In a community assessment, how would you score a person that had modified their lifestyle to avoid complex tasks and ideas so in the last 24 hours had not encountered any. When complex issues do come up (say on average 2 times a month), they either required more time or they required the assistance of their father.

It appears that this person cannot manage complex cognitive issues therefore this would score 5. In the community, through conversation, you could discuss a complex issue and from the discussion you should get a feel for the person’s ability to understand and deal with the complex issue.

Expression

If a person 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 person 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 person needs extra time.

Social Interaction

Is needing encouragement to leave your room seen as more than 25% of the time? i.e. scores 3?

Scoring depends on how often the person requires input for this and other input in the Social Interaction Item in the 24 hour period. For Cognition Items, it is a percentage of time they require input in the 24 hour period, not the lowest ability as with the Motor Items.

How do you determine the score when using medication (chemical restraint)? If an anti-depressant works over a 24 hour period does this mean the person would score a 1?

The medication indicating a FIM Score of 6 for Social Interaction is a regular dose of a common anti-depressant/anti-anxiety medication that is taken daily.

For a FIM Score of 2 for Social Interaction a chemical restraint is given PRN (when necessary) due to an unforeseen escalation of adverse behaviour.

For a FIM Score of 1 for Social Interaction a person has a regular dose of a chemical restraint for to control their behaviour i.e. an antipsychotic medication.

If unsure ask a medical officer.

Are IM injections considered a medical procedure like IV injections/infusions?

If the IM medication given is used to change behaviour, it is not considered the same as IV Fluids. If the IM medication is given for altering behaviour FIM is scored and the question must be asked “why and for what % of time in the 24 hour period is it being given?”

If it is given PRN for adverse behaviour more than 26% of the 24 hour period, it would be scored level 1 – Total Assistance. A score of level 2 – Maximal Direction (or higher) indicates, the person can manage their own behaviour 25% or more of the time with or without chemical or other restraint.

If someone is prescribed Seroquel (antipsychotic sedative) with a history of schizophrenia, but is unable to explain if it’s to control social interaction do you assume it is and score 6 maximum?

Yes, this medication is captured in the Social Interaction item. The discussion would need to be around whether it is used as a chemical restraint or not to decide whether the score is a 6 or a 1 if taken on a regular basis or 2 if PRN. Ask the question ‘What the consequences for behaviour be if this medication was withdrawn’?

Problem Solving

A person is considering bathroom modifications for when they return home. They are planning to discuss this with the occupational therapist, but having mild difficulty making the appropriate decisions about their home environment. How do you score them?

The score is 6 - they can solve complex problems with “only mild difficulty”. The person has recognised the ‘complex’ problem and had asked for the appropriate assistance.

If a person requires another person to manage finances due to spending disinhibition would this score them a 5 for problem solving?

Is it just the spending situation this person needs assistance or also while going about their usual ADL’s? If they require supervision in other areas also then the score could be lower than a 5.

It is not easy capturing all of a person’s need for assistance, especially in the community, with the FIM, therefore we always recommend providing a narrative to highlight issues FIM does not identify.

In a community assessment, how would you score problem solving if the person had modified their life so problems to solve were minimal and they had not encountered any in the past 24hours? However, if they did encounter problems they had difficulty actioning solutions and so left them unsolved?

It appears that this person cannot manage solve more than basic problems and therefore wouldn’t score higher than a 5. If basic problems were also left unsolved when they were encountered they would score a 1.

Memory

If a person is in PTA, do they automatically score 1's for all of the cognitive items?

No, you still assess the person’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. If the scores are low, it's because of their actual functional performance and not just because they are in PTA.

How do I score a person who has died unexpectedly?

In the event of a death, it is not possible to complete an end FIM assessment, therefore in this situation leave the end FIM scores blank.  However, if your team wants to record the functional gain achieved prior to the unexpected death, then enter the end functional score for the person that reflects their level of function at that point in time.

NOTE 1: Where the mode of episode end is ‘death’, for the purpose of outcomes analysis AROC considers the episode ‘incomplete’, that is, the person did not complete their rehab program and their episode is not included in outcomes analysis.

NOTE 2: Some information systems or services have business rules requiring end FIM assessment scores to be entered. If this is the case, then enter 1 for all end FIM scores (a total of 18).

 

I am completing a Discharge FIM, for a person who has been transferred to another hospital. Prior to the transfer, the person was requiring full assistance for all self-care activities and/or they were unable to be assessed for any changes in their FIM motor scores because they were acutely unwell? Do I give it a score of 1?

Discharge FIM can be entered in two ways:

1. Score the FIM to reflect the function of the person prior to their deterioration that caused their transfer to acute care or another hospital.
2. Leave the end FIM scores blank. NOTE:Some information systems or services have business rules requiring end FIM assessment scores to be entered. If this is the case, then enter 1 for all end FIM scores (a total of 18).

We encourage the first option as it provides the care team with feedback on the function the person has been able to achieve. However, where the end FIM is unknown and it is not possible to get an end FIM, leave the end FIM scores blank (see Note above).

Where the Mode of Episode End is recorded as Discharged/Transferred to another hospital, AROC considers the episode ‘incomplete’, indicating the person did not complete their rehabilitation program. Incomplete episodes are not included in outcomes analysis but are analysed separately.

How do we end the episode  for a person 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?

This does happen occasionally. As long as it is definite that the person 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 person*
3. Put the original suspension date as the end date for the episode
4. Give the appropriate reason for episode end

* Ideally, score the FIM to reflect the function of the person prior to their deterioration that necessitated their transfer to acute care. We encourage this option as it provides the care team with feedback on the function the person had been able to achieve.

 

Otherwise, where no end FIM assessment was completed prior to the transfer to acute care  and it is not possible to derive  an end FIM score from notes, leave the end FIM scores blank.  Where the mode of episode end is ‘transferred to acute care’, for the purpose of outcomes analysis AROC considers the episode ‘incomplete’, that is, the person did not complete their rehab program, and their episode is not included in outcomes analysis.

NOTE: Some information systems or services have business rules requiring end FIM assessment scores to be entered. If this is the case, then enter 1 for all end FIM scores (a total of 18).

Can I tick 'Discharged/Transferred to other hospital' for Mode of Episode End, if a person’s rehabilitation episode ends because they become medically unwell and they are transferred to another hospital?

Select 04 - Discharged/Transferred to Another Hospital for Mode of Episode End if a person is transferred to another hospital. Other changes of care type options are for patients that remain at the same hospital. For example, if a person becomes medically unwell, and their care type is changed to acute and they transferred to a different ward in the same hospital, select 05 for care type change and Transferred to a Different Ward.

Where does the benchmark LOS and FIM change come from? Are they listed in the Benchmark report?

AROC LOS and FIM Change Benchmarks are published on the AROC website. They are derived six monthly using the latest 12 months of data submitted to AROC. Each benchmark figure is the average of the values for the relevant episodes.

 

What is the AROC resource tool that has a recommended LOS attached to the impairment code?

It is called the AROC Benchmarking Calculator and is located on the AROC website under Tools and Resources.

Please note that this tool should be re-downloaded following the bi-annual release of the AROC Reports to ensure the most current version is being used. To use the tool, fill in the white boxes on the left and FIM scores then click enter to obtain the AN-SNAP Class and benchmark LOS and FIM Change.