UNDERSTANDING
THE FIM
Functional
Independent
Measure
Part 1
GOALS
Understand what the FIM is & how it is used
 Understand FIM terminology
 Understand how to accurately document
 Understand how scores effect payments &
length of stay
 Understand differences between admission &
discharge FIM
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FIM
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Performance-based functional assessments
which take into account the social and
physical contexts of the person
Measurement of functional abilities and
outcomes must relate to real-life situations
and settings
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Emphases of rehabilitation programs include
improving the functional status of individuals
through a system of interdisciplinary
interventions
Outcomes are determined by periodic
reassessment of functional changes over
time
FIM Instrument Philosophy

The 18 item (motor & cognitive), 7 level FIM
instrument allows clinicians to measure the
effectiveness of rehabilitation interventions
and to describe the outcomes in a uniform
way, with respect to functional status and
burden of care.
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The burden of care represents the amount
of assistance, in hours per day, that is
required to help the patient, once at home, to
perform basic personal care tasks.
This can be translated into financial cost.
Payment by medicare (CMS) and other
insurances is based on the justification that
the burden of care is such that the patient
must be on the rehabilitation unit.
Burden of Care

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Refers to the type & amount of assistance
required for a disabled individual to perform
basic life activities effectively
Considers:
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Time
Personnel
Assistive devices
Support the Burden of Care!
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All disciplines, all environments, 24 hours a
day
Each FIM item MUST be scored every 24
hours
Documentation of the burden of care by
everyone is imperative.
IRF PPS Payment System
IRF PPS Payment

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Payment is based on length of stay (LOS)
and case mix groups (CMG)
CMG is a patient classification system which
groups together patients with similar resource
utilization needs
These are determined from admission FIM
data
IRF PPS Payment

Therefore:

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Scoring must be an accurate assessment of the
patient’s functional status
Scoring must demonstrate all we do
Admissions FIM - Implications of
Inaccurate or Higher Scoring TBI

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FIM motor rating of 53.5 with a cognitive
rating of 24 gives LOS of 8 days and $7100
FIM motor rating of 45 with a cognitive rating
of 24 gives LOS of 10 days and $9600
FIM motor rating of 45 with a cognitive rating
of 23 gives LOS of 13 days and $11800
Admissions FIM -Implications
of Inaccurate or Higher
Scoring – LE Fracture

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FIM motor rating of 43 gives LOS of 9 days
and $9000
FIM motor rating of 42 gives LOS of 12 days
and $11800
FIM motor rating of 33 gives LOS of 14 days
and $14300
Activity Did Not Occur

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The expectation is minimal use of this
selection
You must document the reason activity did
not occur
Use only when the patient did not perform the
activity AND the helper (therapist, nurse, or
family member) did not perform the activity
for the patient during the entire 24 hour
assessment time frame
Activity Did Not Occur – For
Example:

If the patient did not transfer to or from the
bed or chair and a helper did not use a
mechanical lift or perform the activity for the
patient during the entire shift the
documentation represents, then it indicates
that the patient never got out of bed.
Activity Did Not Occur –
Justifiable Reasons

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Activity is unsafe (stairs for a person with LE
paralysis)
Current medical status prohibits (walking for
a pt. unable to bear weight on LE’s
Patient refuses (pt refuses to dress in
clothing other than hospital gown or refuses
to be dressed by a helper)
Activity Did Not Occur –
Implications for Accurate
Documentation

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To ensure we are capturing the burden of
care – avoid using the selection of “activity
did not occur”
When an activity is performed at the end of a
shift (toileting or showers at end of night shift)
make sure to chart the activity (may need to
open a new note if documentation has
already occurred).
Where Can I Obtain
Information on Burden of
Care?
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Credible reports of performance can be
taken from the patient, other staff members,
family or friends
Credible implies that the patient or family
member is cognitively intact
Important Reminders
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You must understand the definition of the
each item in order to document accurately
Do NOT merge tasks
Do not rate simulations, clinical judgments
NEVER copy and paste from a previous
document because your FIM scores will not
be recorded
Each FIM item MUST be scored every 24
hours
Important Reminders
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A number does not support a number! (You must
supply detailed documentation within the
document.)
Min, Mod or Max does not support a number.
(You must document why the need the assistance,
i.e., decreased balance, decreased strength)
“More than reasonable time” to complete a task
independently is defined as 3 times the norm and
would be scored as modified independence (6).
Important Reminders

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If in a hurry & don’t have time to allow the patient
to do a task & the therapist/nurse does it for the
pt, this is max assist.
Consider: How much assist did the pt require in
this point in time? Who performed the task? Do
not modify the assist in order to factor in how
busy you are. If you do perform the task for a
patient due to your time constraints, document
the assistance and the reason (i.e. time
constraints) this level was needed to perform the
task.
Important Reminders

Plan the care you provide by allowing
adequate time for the patient to perform the
task versus performing the task for the
patient. This is rehab, doing the task for the
patient should be a rare occurrence.
Summary
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Read the prompts carefully each time in order
to document accurately
Remember we are documenting the burden
of care required to help the patient at home
perform basic personal tasks
Burden of care can be translated into
financial cost
Careful documentation will support the
burden of care and our payments