Documentation Elements

Transfer type, level of assistance, cues, equipment, and outcome should all be noted in the medical record as an objective finding.

These elements are objective because they are performed and measured in a standardized way and are repeatable.

PTAs, PTs and rehabilitation personnel work as a team to provide consistent care with functional mobility tasks. Consistency in terminology is critical to ensuring continuity of care, patient safety, goal setting, and progressions.

In every day documentation, progress reports, and discharge summaries, level of assist is documented based on the amount of physical work a patient can perform during the transfer

For example: as a PTA you may read this in the objective findings (O) of the evaluation:

O: mod A stand-pivot w/c to bed with cues for pacing and safety.

ACTIVE LEARNING EXERCISE: Try to describe this in a paragraph format. Write out a summary of this objective finding using language that a patient's family member can understand. Share your family-verson on the CAN YOU HELP ME forum for feedback.

There is one short answer question on the PNP FIM quiz like this active learning exercise, and documentation is a progressive skill you will apply in lab and lecture exams.

Transfers are assumed to be performed by one person unless otherwise stated. If additional personnel or equipment is required for patient safety, this should be reflected in the documentation. For example: "O: Min A x 2 slide board transfer w/c to car", includes transfer type, personnel, level of assistance, and equipment.

 

Functional Independence Measure (FIM)

In acute rehabilitation and skilled nursing facilities, multidisciplinary teams periodically evaluate and document patient status using a numeric scale, known as the Functional Independence Measure (FIM). FIM Assessment categories include:

FIMs are used most often for patients with neurological conditions. Quantitative changes in FIM levels confirm the patient is making progress toward functional goals and assist with appropriate discharge planning. PTs and PTAs are often consulted to assess and document mobility FIM levels.

FIM levels are not used as a part of daily documentation. FIM is used as a standardized measure to look at the whole patient, and is completed periodically as an interprofessional team. Standardized measures for both FIM levels and transfer assistance lend consistency and continuity in systems of measurement.

 

Assist Level and FIM Level Categorization

Here's a quick tip from Christina about FIM levels

 

 

ASSIST LEVEL

ABBREVIATION

FIM LEVEL

DEFINITION

 

 

 

 

NO HELPER

Complete Independence

I

7

All tasks are performed safely without modification, assistive devices or aids and within reasonable time

Modified Independence

Mod. I

6

One or more of the following are true about the activity:

--requires assistive device

--takes more than reasonable time

--there are safety (risk) concerns

Stand by Assistance

 

Supervision or Set-up

SBA

Or

S

5

Requires no more than standby, cueing or coaxing without physical contact or helper sets up needed items or applies orthoses

 

 

 

 

 

HELPER

Contact guard assistance

CGA

4

Variation of minimal contact assist where subject requires contact to maintain balance or dynamic stability

Minimal contact assistance or minial assistance

Min contact A

Or

Min A

4

Requires no more than touching & expends 75+% or more of the effort; assistance is needed to lift one limb

Moderate assistance

Mod A

3

Requires more help than touching or expends 51% to 75% of the effort; assistance is needed to lift two limbs

Maximal assistance

Max A

2

Subject expends 26% to 50% of effort

Total assistance

Total A

1

Subject expends less than 25% of effort; two or more provide assistance

 

 


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