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.
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.
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.
Upper body dressing
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.
Lower body dressing
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.
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?’