FUNCTIONAL INDEPENDENCE MEASURE (FIM)
Variable 152
date of last revision: 04/01/06
DEFINITION:
The FIM is a measure of disability. It is intended to measure what the person with the disability actually does, not what he or she ought to be able to do, or might be able to do if certain circumstances were different. It is to be completed within 72 hours after Rehab Admission and again within 72 hours before Rehab Discharge.

FIM data are to be collected according to the current (4/1/04) IRF-PAI coding instructions * IRF-PAI Coding Instructions: 4/1/2004 version (http://www.udsmr.org/pdfs/irfpaimanual040104%20(1).pdf ) , supplemented by any further instructions in your syllabus. Information about the FIM can be found in the IRF-PAI manual in section III, pages 40-57, Appendix H, and pages 29-34. A copy of the FIM-related sections of this manual should be in your syllabus *binder (if your center maintains a binder), in Appendix A. If it is not possible for your Center to follow the correct manual, notify the TBINDC.

Information about the FIM is available from COMBI at these two links: Introduction (COMBI) (http://www.tbims.org/combi/FIM/index.html); Background (COMBI) (http://www.tbims.org/combi/FIM/fimbg.html).

* IRF-PAI instructions used between 1/2002 and 4/2004 (http://www.cms.hhs.gov/InpatientRehabFacPPS/downloads/irfpai-manualint.pdf).
* Summary of the differences between the 4/2004 instructions and the 1/2002 instructions (http://www.cms.hhs.gov/InpatientRehabFacPPS/downloads/irfpai-manual040104.pdf).
CODE:
7 Complete Independence (Timely, Safely)
6 Modified Independence (Extra time, device)
5 Supervision (pt does 100%)
4 Minimal Assist (subject does 75% *or more of task)
3 Moderate Assist (50 - 74% of task)
2 Maximal Assist (25 - 49% of task)
1 Total Assist (subject 72 hours)
*0 Activity does not occur. (Use only at admission and only for #1-6,10-15; else use code "9".)
66 Variable did not exist

Items 8b and 9b
7 No accidents
6 No accidents, uses device (e.g.,catheter, ostomy)
5 One accident in the past 7 days
4 Two accidents in the past 7 days
3 Three accidents in the past 7 days
2 Four accidents in the past 7 days
1 Five or more accidents in the past 7 days
9 Unknown / assessed at *more than 72 hours
66 Variable did not exist

Item 14: Primary mode of locomotion on discharge
w Walking
c Wheelchair
9 Unknown

Item 17: Primary mode of comprehension
a Auditory comprehension *more than 50% of the time
v Visual comprehension *more than 50% of the time
b Both used equally
9 Unknown

Item 18: Primary mode of expression
v Verbal expression *more than 50% of the time
n Nonverbal expression *more than 50% of the time
b Both used equally
9 Unknown

CHARACTERS:
1 numeric
2 numeric
1 alpha-numeric
NOTE:
All FIM items must be scored. Record what patient actually does. If FIM assessment cannot be completed within the 72 hour window, it should still reflect the patients' status within that time period. If this is not possible and the assessments are done out of the 72 hour window, code with 9's. Every effort should be made to obtain the FIM assessments; however, if any items are not assessed, use code 9 -- do not leave blanks.

For admission item #14, if patient is walking and not using wheelchair, code item 14b (wheelchair) "8=not applicable". If patient is unable to walk on admission, code item 14a (walking) "1=total assist". If, at discharge, patient is walking AND using a wheelchair, code 14 (mode) as the more frequently used mode of locomotion. Do not use the code "b=Both" (as is indicated by UDS instructions). If FIM scores provided by your hospital include "b" codes, use all sources of information to determine the more frequent mode of locomotion at the time of evaluation andcode either "w" or "c" as appropriate. If the more frequent mode of locomotion cannot be determined, code "9".

According to the UDS Procedures for Scoring the FIM, "if the subject would be put at risk for injury if tested or does not perform the activity, enter 1". Use this same rule for the TBI Model Systems FIM data collection.

According to the UDS procedures for scoring the FIM, "the mode of locomotion for FIM item #14 (Walk/Wheelchair) must be the same on admission and discharge; if the subject changes the mode of locomotion from admission to discharge (usually wheelchair to walking), record the admission mode and score based on the most frequent mode of locomotion at discharge". Therefore, for the TBI Model Systems FIM data collection for FIM item #14, score both modes of locomotion (Walking and Wheelchair) on admission. The total admission score will be calculated by the computer and based on the UDS procedure described above (i.e., if the discharge mode is walking, the admission score for walking is used; if the discharge mode is wheelchair, the admission score for wheelchair is used.

If patient has an intermittent acute care stay during inpatient rehabilitation, use the FIM scores from the first rehabilitation admission and the last definitive discharge. In addition, if a patient has an intermittent stay which is longer than 30 days, it is then considered a system discharge and the discharge date from rehabilitation is the system discharge date and the FIM scores should correspond to that date.
"Level of assistance" (part a) and "Frequency of accidents" (part b) are recorded for #8 (Bladder Management) and #9 (Bowel Management).

For items 1-6 and 10-15 at the admission evaluation only, if patient does not perform the activity and a helper does not perform the activity for the patient, assign code "0=Activity does not occur". If the patient is simply not observed performing an activity, do not code "0" until all available sources of information have been consulted (e.g., other clinicians, medical record, family members). If at discharge evaluation an activity is not performed, assign code "1=Total assistance" (do not use the "0" code at the discharge evaluation).

For #8 (Bladder Management), if patient does not void (e.g., renal failure and on hemodialysis), assign code "7=Complete independence".

According to new FIM instructions (effective 1/1/02), all FIM items now have an "assessment time period". The person's score on a given FIM item is determined by his/her functional level during this "assessment time period"--a specified number of days prior to the evaluation. (FIM instructions prior to 1/1/02 did not indicate an assessment time period.) The assessment time period for all FIM items (except 8b and 9b-see below) is 3 days. Scoring reflects the patient's poorest (most dependent) functioning during the assessment time period1. The evaluation is therefore not a snap-shot of the patient's performance at the time of evaluation, but a summary of performance over the entire assessment time period.

For items 8b and 9b (number of bladder accidents, number of bowel accidents), the assessment time period is 7 days-that is, the number of accidents is counted across the 7 days prior to the patient's FIM evaluation. Because the admission FIM evaluation must be done at the end of the first 3 days after rehab admission, the assessment time period therefore includes the 4 days prior to rehab admission. If information is not available from this 4-day period, then treat only the 3 days after rehab admission as the assessment time period. No adjustment in scoring of items 8b and 9b is made when the assessment time period is shorter than 7 days.

Wearing of eyeglasses causes Comprehension to be scored "6" only if the person's primary form of comprehension is visual (rather than auditory, which is usually primary).

See: Properties of the FIM instrument (COMBI) (http://www.tbims.org/combi/FIM/fimprop.html)


1 However, the current training manual qualifies this, as follows: "The patient's score on measures of function should not reflect arbitrary limitations or circumstances imposed by the facility. For example, a patient who can routinely ambulate more than 150 feet throughout the day with supervision (score of 5 for FIM Locomotion: Walk/Wheelchair item), but who is observed to ambulate only 20 feet at night to use the toilet because that is the distance from his/her bed, should receive a Walk score of 5 rather than a lower score" (IRF-PAI Training Manual 1/16/02, page III-4).
TRAINING:
FIM training will follow guidelines from the Uniform Data System (UDS). It is the responsibility of each center to assure that all staff who perform FIM assessments (Form I and Form II) are certified by a recognized credentialing organization (e.g., UDS, e-Rehab) and remain certified for the duration of the time that they collect data/assess patients for the TBIMS National Database.
SOURCE:
Uniform Data System for Medical Rehabilitation
232 Parker Hall
SUNY South Campus
3435 Main Street
Buffalo, New York 14214 3007
(716) 829 2076; FAX (716) 829 2080

The IRF-PAI instructions for the FIM are disseminated through the website of The Centers for Medicare and Medicaid Services. For information about the CMMS, go to: http://www.cms.hhs.gov/researchers/projects/APR/2003/facts.pdf.

EXAMPLE:
[It is not possible to display information in columns in the live syllabus, which is important for displaying the example for V152. A more neatly formated example is available at: FIM example.]

Admission Discharge

SELF CARE ITEMS:
2 4 1. Feeding
1 4 2. Grooming
2 3 3. Bathing
3 5 4. Dressing Upper Body
3 5 5. Dressing Lower Body
2 4 6. Toileting

SPHINCTER CONTROL:
3 5 8. Bladder Management
4 5 a. Level of assistance
3 6 b. Frequency of accidents
4 5 9. Bowel Management
4 6 a. Level of assistance
5 5 b. Frequency of accidents

MOBILITY ITEMS:
Transfers technique
3 4 10. Bed, Chair, Wheelchair
4 6 11. Toilet
3 3 12. Tub or Shower
Locomotion
3 14a. Walking on admission
3 14b. Wheelchair on admission
w 3 14. Walking/Wheelchair on discharge (w/c/9)
3 3 15. Stairs

COMMUNICATIONS:
b 7 b 7 17. Comprehension (a/v/b/9)
v 6 v 6 18. Expression (v/n/b/9)

PSYCHOSOCIAL ADJUSTMENT ITEMS:
6 5 22. Social Interaction

COGNITIVE FUNCTION:
5 6 26. Problem Solving
4 5 27. Memory

QUESTIONS & ANSWERS:
QUESTION: Does the database calculate total admission FIM using walking score or wheelchair score? Is that score directly related to mode of locomotion at discharge? E.g., if walking at d/c then is the walking at adm score used in calculating total score? 
ANSWER: Walking score at admission is used if peson is walking at dc, and wheelchair at acmission score is used if person is in wheelchair at dc. (This answer can be found in the Data Dictionary in the database.)  (11-26-2003)

Traumatic Brain Injury Model System National Database Live Syllabus V10.3
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