Cognitive Level Determination Score Sheet-2014
ACLS-5 leather lacing
In previous versions, the screen ended when a person was unable to complete three correct stitches for any one of the 3 tasks. This version encourages persons to
progress through all three tasks, even if they do not complete three correct stitches for any one task. All tasks are allowed 2 demonstrations if needed, but screener must
first remove any incorrect stitches.
Running stitch (3.0-3.4)
“I am interested in how you follow directions and concentrate. I will show you how to do a stitch now, watch carefully.
Take the shoelace tip and push it through the next hole. Pull it tight. Push the shoelace tip through the next hole.
Pull it tight. Don’t skip any holes. Now you do it.”
Check if
completed
Task Accomplished
Level/Mode
Does not reach for or actively grasp leather or shoelace. Fingers may close
around leather when it is placed in their hands.
Actively grasps leather or pushes it away. May not attempt to grasp
shoelace or may grasp shoelace and move it in a random manner
Pushes shoelace tip through at least one hole anywhere on the leather
Completes at least 3 running stitches in consecutive holes with any of the 3
laces. Stitches may be anywhere on the leather.
Less than 3.0
3.0
3.2
3.4
Whipstitch (3.4-4.4)
“See how the leather has a light, smooth side and a dark, rough side? Always keep the smooth, light side up as you do
each stitch, being careful not to twist the lacing. Now I will show you another stitch. Watch me carefully. Take the
lacing and bring it around to the front, over the edge of the leather. Push the needle through the hole and tighten it.
Make sure the lacing isn’t twisted. Don’t skip any holes. Please make 3 stitches.”
“does yours look like mine?” They answer no Can you fix it? They answer yes
There is a mistake, please try to find it & fix it.
I am going to make a mistake to see if you can correct it. Can you fix it? #1) on the back of the leather, push the needle through
If there are unrecognized errors, say
previous stitch from right to left forming a cross. (if corrects, then proceed to #2) make a clearly visible twist in 2 of the stitches
Check if
completed
Task Accomplished
Level/Mode
Completes only 1 whipstitch going from front to back OR completes 1 or
more stitches that go over the edge of the leather from back to front. When
asked to find and fix their mistake, does not find visible twisted lace and/or
cross-in-back-errors.
Completes at least 2 whipstitches in consecutive holes going front to back.
Stops before all holes are filled. Recognizes they completed a running stitch
instead of the sample whipstitch. When cued, does not recognize twisted or
cross errors.
Completes at least 3 whipstitches in consecutive holes & stops before using
all the lacing/holes OR completes multiple whip stitches until all lacing or
holes are used. When cued, does not recognize twisted or cross errors.
Completes at least 3 whipstitches in consecutive holes and stops before all
holes or lacing is used. When asked to find and fix their mistake, finds at
least one visible twisted lace or cross error, but does not try to correct.
Completes at least 3 whipstitches in consecutive holes. When asked to find
and fix their mistake, finds all visible twisted lace errors by removing entire
stitch. Fails to fix a twisted lace error without removing stitch.
Recognizes and corrects cross and twist errors spontaneously. Corrects at
least 1 twist error spontaneously or upon request without removing stitch.
3.4
3.6
3.8
4.0
4.2
4.4
ACL
BIMS
Clock
RTI
Level/Mode ______
score ____ last MDS
Drawing ___/4
_______
Observations:____________________________________________________________________________
_______________________________________________________________________________________
Resident:_______________________ MR#_______Therapist: ____________________
___/___/___
Single cordovan stitch (4.2-5.8)
Step 1 attempt using sample only ; Hand the patient the sample:
“Please make 3 stitches without me showing you how to make them. If you can’t figure it out, I will show
you.” If needed, offer encouragement such as “keep trying, this stitch is hard, or you are making progress.” Do not offer problem solving cues at this time.
Step 2 attempt with a hint:
If not correcting errors, or becoming overly frustrated, offer assistance by saying “Would you like a hint?” Proceed to offer one verbal cue such as “look
at how you are going through the hole, is there another way to tighten the lace, or you have the first part right.”
Step 3 attempt with a demo if continues to be unsuccessful:
“Would you like me to show you how? Watch me carefully. Bring the needle to the front of the leather and
push the needle through the next hole towards the back of the leather. Don’t pull the lace tight but leave a
small loop in it. Bring the lace to the front of the leather, but this time put the needle through the loop you
have made. As you go through the loop, keep the needle to the left of the lace. Pull the lace through the loop.
Tighten the stitch by pulling the lace from the back, and then by pulling the long lace end. Make sure the
lace isn’t twisted. Please do three stitches.”
Check if
completed
Task Accomplished
Level/Mode
Does not complete 3 correct single cordovan stitches in consecutive holes after 2
demonstrations. Makes repeated whipstitches or running stitches. Does not
recognize errors OR recognizes errors but does not attempt to correct OR
recognizes and attempts to correct error by reversing only last action performed
Does not complete 3 correct single cordovan stitches in consecutive holes after 2
demonstrations. Makes whipstitch and immediately pushes needle through loop
from back as if it were 1 step. Lacing is under but not wrapped around loop OR
pushes needle through hole back to front and through loop front to back. Does
not recognize incorrect stitch OR attempts to correct an identified error by
removing entire stitch and repeating unsuccessful methods.
Does not complete 3 correct stitches in consecutive holes after 2 demonstrations.
Pushes needle from front to back through hole and loop then pushes through loop
twice or through next hole. Stitch not tightened OR needle pushed front to back
through hole and loop with needle to right of lace as it exits from back of hole.
Stitch not tightened. Errors not recognized OR attempts to correct identified
errors by removing stitch and varying direction in which needle is pushed
through hole &/or loop.
Does not complete 3 correct stitches in consecutive holes after 2 demonstrations.
Pushes needle from front to back through hole and loop, and then pulls on lace
end to tighten stitch. Does not tighten stitch in demonstrated sequence. Does not
direct needle consistently to right or left of lace when pushing through loop. Does
not recognize errors OR uncertainty about whether a stitch is incorrect. Attempts
correction by pulling harder on lace or varying direction of pull.
Does not complete 3 correct stitches after 2 demos. Pushes needle from front to
back through hole and loop. Tightens by pulling lace in various ways. Does not
tighten in demonstrated sequence. Spontaneously recognizes errors. Attempts to
correct errors one at a time by changing methods of untwisting and tightening
lace. Discovers successful solutions, but does not repeat these solutions to
complete subsequent stitches.
Completes 3 correct stitches after 2nd demo. Pushes needle from front to back
through hole and loop and tightens stitches by pulling on lace in demonstrated
sequence. Discovers successful solutions to correct errors and repeats solutions
in subsequent stitches.
Completes 3 correct stitches after 1 demo. Tightens in appropriate sequence and
so tension matches sample stitches.
Completes 3 stitches without a demo but requires one verbal cue
Completes 3 stitches without a demo or cue using observation & trial/error
4.2
4.4
4.6
4.8
5.0
5.2
5.4
5.6
5.8
Ask the person to draw the face of a clock, putting the numbers in the correct positions. After he/she has drawn a circle and placed
the numbers in position, ask him/her to draw in the hands indicating ten minutes after eleven.
Draw a clock
Draws closed circle
1 point
Inserts 2 hands
1 point
Includes all 12 correct #s
1 point
Places hands in correct position
1 point
Routine Task Inventory Score Sheet: Physical Scale
Name_______________________
Date __/__/__ MR__________
Check the level that best describes observed performance or caregiver’s report of performance.
Grooming
1
2
3
4
5
Ignores personal appearance. May not hold head up or keep head turned to the side to cooperate with
caregiver
Aware of caregiver’s help. May move to assist caregiver or actively resist.
Does daily grooming of teeth, washing face/hands. Supplies must be placed in front of them or they
may quit before the task is finished and require prompts to finish. May need 1:1 supervision. May be
unconcerned about dirty hair, unkempt nails. May not be safe with sharp or hot objects (razor, curling
iron.)
May not be aware what time of day grooming is usually done.
Initiates and completes grooming. May neglect the back of the head or body or miss spots they cannot
see. May be concerned about appearance and ask for helping selecting and applying grooming
products.
Initiates and completes grooming.
Dressing
1
2
3
4
5
Ignores clothing unless cold or uncomfortable
Aware of caregivers efforts to dress. May alter position to assist hand in sleeve, etc. or may not use
enough force to get the garment on without help. May resist getting dressed. May need help for
sitting/ standing. May need help adjusting clothing throughout the day to keep them on correctly
Puts on shirt, pants/ skirt, underwear, and shoes. Clothes may be laid out by caregiver. May need help
with fasteners. May be unconcerned about the appearance of their clothing or be unaware of the need
to change clothes based on time of day, weather, soiling, etc. and resist requests to change. May be
unconcerned about errors such as garments on backwards, or underwear on top
Follows a routine for getting dressed without help. May have errors in button alignment, shirt not
tucked in back or labels showing, but corrects when pointed out. May disregard errors in back or
poorly matching clothes.
Selects own clothing and dresses without error
Bathing
1
2
3
4
5
Bathed lying in bed or lifted into tub
Assists caregivers efforts to bathe, may stand or sit while soap/shampoo are applied by caregiver. May
stand/sit as directed, may use grab bars when directed. May be scared of falling & resist entering
shower.
Can get in/out of tub and use bathing articles without help. May need assist w/water temp, to bathe or
dry all areas thoroughly. May need help to sequence through the use of toiletries
Follows a routine at usual time for bathing without help or set up. May need help to keep supplies
handy for use. May leave bathroom unkempt. May need to be checked to be sure back of head is
washed, deodorant applied. May need help finding supplies if not in usual location.
Bathes without help and checks own quality.
Toileting
1
2
3
4
5
No awareness of need to void or does not communicate need for help. May cooperate with bedpan
placement
Aware of need to void & attempts to go to toilet. May not know where the bathroom is or not allow
enough time to get there. May have trouble opening door, leave door open when going, adjusting
garments, or need cues to use toilet paper effectively & remembering to flush
Recognizes need to go, finds bathroom, opens door, turns to sit, manages clothing, voids, wipes, and
pulls up pants. May leave door open & forget to flush. May need cues to wipe clean, wash hands, zip,
or tuck in shirt.
Cares for self at toilet completely. May need clothing errors pointed out or need reminders to go
before leaving home
Can look around for a bathroom in a new setting without direction
Name_______________________
Date _/_/_Therapist_______________
Routine Task Inventory Score Sheet: Communication Scale
Check the level that best describes observed performance or caregiver’s report of performance.
Listening/Comprehension
1
Locates direction from which sound is coming when sound accompanied by calling name or other
additional cures. May not move head or eyes to respond, may be very slow to respond (1-2 mins.,) may not
show understanding of words but may respond to sounds like a bell or name.
2
Understands & follows simple directions using single words/short phrases related to immediate physical
comfort. May not sustain attention unless accompanied by demonstrated action. May require: repetition, a
slow rate between words, a long duration of spoken word.
3
Understands & follows simple directions & forms immediate memory for messages comprised of phrases
or short sentences related to immediate personal interests in surroundings. May be distracted by irrelevant
stimuli, misunderstand information, not maintain focus on topic, or may not understand a message given at
a normal rate & duration
4
Understands & acts on info contained in simple conversation about highly familiar topic & maintains focus
on topic that conforms with past experiences. May not understand new info, new info may need to be
repeated slowly or accompanied by pointing to locations, showing how, or writing down a message. May
not listen to the conversations of others.
5
Listens to & understands conversations & new info related to past & present experiences. May understand
future events (such as warnings) when cause & effect is demonstrated may not understand explanations in
new situations & ignore warnings, may not request clarification or anticipate the need for additional info,
may present own view but not understand the points of view of others.
6
Understands conversations & new info related to planning & organizing future events. Considers
hypothetical possibilities when verbally expressed & anticipates safety hazards.
Talking/Expression
1
Communicates pain or fear by verbal expression and/or gesture. May not: stop screaming, gesturing when
problem has been acknowledged, communicate displeasure or discomfort, initiate a sound/gesture for long
periods of time
2
Communicates physical comfort/discomfort/fear via single words and short phrases. Words may be
produced at a very slow rate, spoken very softly or unnecessarily loudly, & may contain sounds that are
unintelligible to the listener.
3
Communicates simple messages via phrases & short sentences related to immediate interest in
surroundings. May not: maintain topic beyond current manual actions, present info in a logical sequence.
May include irrelevant info, jargon, neologism, or may not adjust rate, tone, volume, speaking distance
when requested.
4
Initiates communication re: immediate goal or need for assist to achieve a personal goal. Converses about
highly familiar topics related to past experiences. May interrupt others, include too little or too much info,
have word finding problems for common words, or use abstract words incorrectly. May adjust rate, tone,
volume, speaking distance only upon request
5
Communicates interesting & irrelevant info from past & present experiences. May not: restate or revise
info according to listener/social circumstance, respond to subtle cue to revise message, or may have word
finding problems for seldom used words or have difficulty learning new words. May react to different
points of view by interrupting/talking. May not shift between speaker/listener roles and contributes too
much or too little to conversation.
6
Communications go beyond personal experiences to consider experiences/needs of others and to anticipate
events that could have an impact on the lives of others
Reading/Comprehension
1
Locates & gives some indication of recognition of pictures, objects, letters, own name when visual stimuli
is accompanied by verbal, tactile, &/or gestural cues. May not show consistent recognition, be very slow to
respond (1-2 mins) or may not be able to speak
2
Reads single words & short phrases related to immediate physical comfort or familiar addresses, greetings,
traffic signs. May not read for up to a minute or require large print with a single word per page or may be
hard to hear/understand if reading aloud.
3
Reads & repeats back or answers questions on cue to 3 simple sentences related to immediate personal
supplement
Adapted from Katz-Allen 2006 Routine Task Inventory RTI: Communication Scale
situation or from familiar headlines, ads, cartoons, or bills. May take 1-2 mins to read the sentences, may
not comprehend the relationship between sentences, may not maintain focus on the context, or may
misunderstand info according to immediate personal needs
4
Reads & gives a verbatim report or answer to questions about 1-3 paragraphs related to a topic of familiar
interest and experience. Reading rate may be decreased. New info may be ignored or misinterpreted. May
not establish a connection between info and personal actions. May ignore most written material.
5
Reads & can answer questions or restate content of lengthy material on familiar topics. May read
newspaper, magazines. May not relate precautions in new situations, commercial product use/road hazard
to own situation. May not be able to answer questions or restate content of new material. May require
demo to comprehend reading of new info.
6
Reads & comprehends new info & applies it when organizing/planning future actions
Writing/Expression
1
May write own name or make random marks. May be very slow to respond in marking, name may be hard
to read or an approximation, may stop before name is complete, may not grasp pencil
2
Writes single words/phrases related to physical comfort or familiar example. May not write when an
immediate elimination of discomfort is needed, may be illegible to unfamiliar readers, may take 1-2 mins
to write 1-3 words, may require repetitive demo of writing a word. May not grasp pencil.
3
Writes simple messages via phrases related to immediate personal interest in surroundings or familiar
example. May be slow to start, fail to complete message once started if distracted, write lengthy illogical
messages, or may not make a connection between writing and communicating.
4
Writes of types (if already knows how) 1-3 simple paragraphs about highly familiar topic or a letter
containing a personal request. Into and concluding sentences may not be present, supporting details may be
sparse or over inclusive, may repeat the same ideas over & over, may be slow to write a dictated message.
Messages may not be delivered. Letter may not be properly addressed or have necessary stamp.
5
Writes or types (if already knows how) multiple paragraphs that restate known info or have simplistic
content. May not: consider the reader’s response, revise material for different readers, adjust
quantity/quality according to deadlines or external factors such as a birthday. May avoid new info or
reproduce it inaccurately.
6
Writes or types multiple paragraphs and pages from an objective point of view, considers reader, follows
an organized format, and delivers material in a timely manner.
supplement
Adapted from Katz-Allen 2006 Routine Task Inventory RTI: Communication Scale