Document ID: chunk:federal_register_of_legislation:F2018L01161:schedule:1
Version: federal_register_of_legislation:F2018L01161
Segment Type: schedule
Provision Reference: sch 1
Character Range: 5826–9744

Schedule 1—FIMTM score sheet

Patient's name:                                 Date of birth:

Type of injury: o Brain injury   o Burn         Date of injury:

Hospital / unit:                                Date of assessment:

Method of administration: o Direct observation

 o Interview with:

Item                                            Score                Is score due to the injury?  Reasons for score

SELF CARE

   1. Eating                                                                    o Yes   o No

  2.      Grooming                                                              o Yes   o No

  3.      Bathing                                                               o Yes   o No

  4.      Dressing – upper body                                                 o Yes   o No

  5.      Dressing – lower body                                                 o Yes   o No

SPHINCTER CONTROL

  6.      Toileting                                                             o Yes   o No

  7.      Bladder management                                                    o Yes   o No

  8.      Bowel management                                                      o Yes   o No

Self-care subtotal

TRANSFERS

                                                                                              Mode: W – Walk

  9.      Bed / Chair / Wheelchair                                              o Yes   o No  C – Wheelchair

                                                                                              B – Both

  10.  Toilet                                                                   o Yes   o No

  11.   Bath / Shower                                                           o Yes   o No

LOCOMOTION

                                                                                              Mode: W – Walk

  12.  Walk / Wheelchair                                                        o Yes   o No  C – Wheelchair

                                                                                              B – Both

  13.  Stairs                                                                   o Yes   o No

Mobility subtotal

COMMUNICATION

                                                                                              Mode: A – Auditory

  14.  Comprehension                                                            o Yes   o No  V – Visual

                                                                                              C – Both

                                                                                              Mode: A – Auditory

  15.  Expression                                                               o Yes   o No  V – Visual

                                                                                              C – Both

SOCIAL COGNITION

  16.  Social interaction                                                       o Yes   o No

  17.  Problem solving                                                          o Yes   o No

  18.  Memory                                                                   o Yes   o No

Cognition subtotal

FIM™ TOTAL SCORE

Administered by:                               FIM™ credentialed: o Yes   o No

Qualification:

Date of assessment:

FIM™ LEVELS

No helper

7 Complete independence (Timely, Safely)

6 Modified independence (Device)

Helper – Modified Dependence

5 Supervision (Subject = 100%)

4 Minimal assistance (Subject = 75% or more)

3 Moderate assistance (Subject = 50% or more)

Helper – Complete Dependence

2 Maximal assistance (Subject = 25% or more)

1 Total assistance (Subject less than 25%)

FIM is a trademark of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. AROC (the Australasian Rehabilitation Outcomes Centre) holds the territory licence for the FIM in Australia.