DATA DICTIONARY For TRAUMA REHABILITATION DATA COLLECTION From Inpatient Rehabilitation Facilities

Transcription

1 OHIO TRAUMA REGISTRY DATA DICTIONARY For TRAUMA REHABILITATION DATA COLLECTION From Inpatient Rehabilitation Facilities OHIO DEPARTMENT OF PUBLIC SAFETY EMS DIVISION 1970 W. Broad Street, P.O. Box Columbus, OH (614) (800) EMS Data Center (614) Effective January 1, 2005

2 Table of Contents Patient Inclusion Criteria...3 Field Definitions...5 Field #1 Rehabilitation Facility Code...6 Field #2 Unique Patient Encounter/Admission Number...7 Field #3 Date Exported...8 Field #4 Zip Code of Residence...9 Field #5 Patient s Date of Birth...10 Field #6 Gender...11 Field #7 Race/Ethnicity...12 Field #8 Date of Onset (date injury occurred)...13 Field #9 Rehabilitation Admission From...14 Field #10 Pediatric Pre-hospital Setting...16 Field #11 Pediatric Living With...17 Field #12 Pediatric Education Category...18 Field #13 Pediatric Educational Setting...19 Field #14 Adult Pre-hospital Living With...20 Field #15 Adult Pre-hospital Vocational Category...21 Field #16 Adult Pre-hospital Vocational Effort...22 Field #17 Transferring Facility ID...23 Field #18 Rehabilitation Facility Arrival Date...24 Field #19 Etiological Diagnosis (ICD-9-CM Code)...25 Field #20 Co-Morbid Conditions (ICD-9-CM Codes)...26 Field #21 Complications During Rehabilitation Stay (ICD-9-CM Codes)...27 Field #22 Disability Assessment Tool Adult/Pediatric (FIM WeeFIM instrument)...28 Field #23 Disability Assessment Score Upon Admission (FIM WeeFIM rating)...29 Field #24 Disability Assessment Score Upon Discharge (FIM WeeFIM rating)...30 Field #25 Date of Discharge or Death...31 Field #26 Discharge Status...32 Field #27 Adult Discharge Disposition...33 Field #28 Adult Discharge Living With...34 Field #29 Pediatric Discharge Disposition...35 Field #30 Pediatric Discharge Living With...36 Field #31 Discharge Referrals...37 Field #32 Transfer to Other Hospital / Facility...38 Field #33 Billed Rehabilitation Facility Charges...39 Field #34 Payment Source...40 Field #35 Adult Rehabilitation Length of Stay...41 Field #36 Pediatric Rehabilitation Length of Stay...42 APPENDICES 1 - Ohio Rehabilitation Facility Codes Ohio Hospital Codes Out of State Rehabilitation, Hospital and Nursing Facility Codes Ohio Nursing Facility Codes... 5 Authority/Mandate... 6 Trauma Registry Advisory Subcommittee... 7 File Key Layout... 2

3 Ohio Trauma Registry Inpatient Rehabilitation Facility Patient Inclusion Criteria Patient s first or initial admission to an inpatient rehabilitation facility who meet one of the following inclusion criteria; 1. Patients whose acute care hospitalization included any of the inclusion criteria; OR 2. Patients who have an Impairment Group Code on admission listed in the table on page 4 Inclusion Criteria ICD-9-CM Diagnosis Codes on discharge from acute care hospital ICD-9-CM Diagnosis Codes ICD-9-CM Diagnoses Descriptions Fractures Fractures, dislocations/sprains, intracranial injury, internal injury of thorax, abdomen and pelvis, open wounds, injury to blood vessels 911.0, 911.1, 912.0, Abrasions/friction burns to trunk, shoulder and upper arm 916.0, 916.1, 919.0, Abrasions / friction burns hip, thigh, leg, ankle, other or multiple sites Contusions and crush injury Burns, injury to nerves and spinal cord, traumatic complications and unspecified injury Smoke inhalation Frostbite, hypothermia and external effects of cold 994.0, 994.1, 994.7, Asphyxiation, strangulation, drowning, and electrocution Child maltreatment and abuse ***OR*** ICD-9-CM Diagnoses E-CODE Anoxic Brain Injury E800 E Uncal herniation E878 E905.0 E906.0 E , Cerebral Edema E950.0 E Pneumocephalus Subconjunctival hemorrhage Traumatic ARDS Epistaxis AND WITH ANY OF THE FOLLOWING External Cause Codes (E-Codes) Acute Care Hospitalization ICD-9-CM Diagnoses Codes EXCLUDED Isolated hip fracture Late effects of injury , , , , Blisters, insect bites , , , , Foreign bodies Acute Care Hospitalization External Cause Codes EXCLUDED E849.0 E849.9 Place of occurrence E850.0 E869.9 Poisonings E870.0 E879.9 Misadventures during surgical and medical care E905.1 E905.9 Venomous animals and plants (except snakes) E929.0 E929.9 Late effects of Accidental Injury E930.0 E949.9 Drugs, medicinal and biological substances causing adverse effects in therapeutic use 3

4 Adult Impairment Group Code on Admission to Rehabilitation Facility Brain Dysfunction Orthopedic Disorders 02.1 Non-traumatic injury * Status Post Bilateral Hip Fractures * must be associated with an acceptable E-code Status Post Femure (shaft) Fracture 08.3 Status Post Pelvic Fracture Traumatic, open injury 08.4 Status Post Major Multiple Fractures Traumatic, closed injury Spinal Cord Dysfunction, Traumatic Paraplegia, unspecified Amputation of Limb (trauma related) Paraplegia, incomplete 05.1 Unilateral Upper Limb above the elbow (AE) Paraplegia, complete 05.2 Unilateral Upper Limb below the elbow (BE) Quadriplegia, Unspecified 05.3 Unilateral Lower Limb above the knee (AK) Quadriplegia, Incomplete C Unilateral Lower Limb below the knee (BK) Quadriplegia, Incomplete C Bilateral Lower Limb above the knee (AK/AK) Quadriplegia, Complete C Bilateral Lower Limb above/below the knee (AK/AK) Quadriplegia, Complete C Bilateral Lower Limb below the knee (BK/BK) Other Traumatic Spinal Cord 05.9 Other amputation Dysfunction Major Multiple Trauma Burns 14.1 Brain + Spinal Cord Injury 11 Burns 14.2 Brain + Multiple Fracture/Amputation 14.3 Spinal Cord + Multiple Fracture/amputation 14.9 Other multiple trauma Pediatric Impairment Group Code on Admission to Rehabilitation Facility Traumatic Brain Dysfunction Burns 2.21 Traumatic, open injury 7.1 Burns 2.22 Traumatic, closed injury 2.9 Unspecified traumatic brain injury Orthopedic Disorders 2.11 Anoxic/Hypoxemic Encephalopathy Orthopedic Conditions Traumatic Spinal Cord Dysfunction 5.11 Status Post Unilateral Hip Fracture 4.21 Incomplete Traumatic Paraplegia 5.12 Status Post Femure (shaft) Fracture 4.22 CompleteTraumatic Paraplegia 5.13 Status Post Pelvic Fracture 4.23 Unspecified Traumatic Paraplegia 5.14 Status Post Major Multiple Fractures 4.24 Incomplete Traumatic Tetraplegia Quadriplegia, C1-4 Amputation of Limb (trauma related) 4.25 Incomplete Traumatic Tetraplegia Quadriplegia, 5.21 Unilateral Upper Extremity above the elbow C Complete Traumatic Tetraplegia Quadriplegia, 5.22 Unilateral Upper Extremity below the elbow C Complete Traumatic Tetraplegia Quadriplegia, 5.23 Unilateral Lower Extremity above the knee C Unspecified Traumatic Tetraplegia Quadriplegia 5.24 Unilateral Lower Extremity below the elbow 5.25 Bilateral Lower Extremity above the knee Major Multiple Trauma 5.26 Bilateral Lower Ext. above/below the knee 6.1 Brain + Spinal Cord Injury 5.27 Bilateral Lower Extremity below the knee 5.29 Other amputation 6.2 Brain + Multiple Fracture/Amputation 6.3 Spinal Cord + Multiple Fracture/amputation 6.9 Other multiple trauma 4

5 Ohio Trauma Rehabilitation Registry Field Definitions Unless specifically indicated, these definitions apply to all fields in the database: ND = Not Documented If the information is probably known but is not documented, or the information is not documented but should have been and would have been knowable. Example: sex NA = Not Applicable If the information requested is not applicable, or the information does not make sense for this field Example: seat belt use for motorcycle crash 0 = Zero Use only for numeric fields when that is what the correct number is. Example: in Length of Stay fields if the patient did not have a LOS in that area NT = Not Tested Use for fields in which the desired data is a laboratory test result when the test was not ordered. Example: for alcohol level, when that test was never ordered UNK = Unknown If the information is unknowable and cannot ever be obtained. That is, there is no way to know the answer, or the information is specifically documented as unknown in the medical record. Example: The time of injury if the patient is found unconscious the next morning 5

6 Field # 1: Values: Rehabilitation Facility Code The facility code assigned by the Ohio Department of Public Safety. 1. Length 4 2. Start Position 1 3. End Position 4 4. Allow blank or not NO 5. Data Type (Numeric, Character). NUMERIC See Appendix 1 ODPS Rehabilitation Facility Codes. Field Instructions: Must be present on all records submitted to the Ohio Department of Safety. A four-digit code assigned by the Ohio Department of Public Safety. This code needs to be entered initially. After initial entry it will automatically be entered for each record. Click Here to return to the Table of Contents 6

7 Field #2: Values: Version 1.0 Effective January 1, 2005 Unique Patient Encounter/Admission Number A number assigned by each facility to the patient at the time of admission. This number should be unique for each patient AND each visit. This number may be referred to as a patient account number. Medical record numbers are typically specific to each patient BUT are frequently the same for all rehabilitation facility visits by the same patient. 1. Length Start Position 5 3. End Position Allow blank or not NO 5. Data Type (Numeric, Character). NUMERIC Field Instructions: Enter the rehabilitation facility s unique patient number for this patient. This record is for audit purposes only and will not be made public. Click Here to return to the Table of Contents 7

8 Field #3: Date Exported Version 1.0 Effective January 1, 2005 Value: Date (mmddyyyy) that this record was submitted to the Ohio Trauma Registry. 1. Length 8 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). DATE Field Instructions: This is a generated field and will be completed when the record is exported to Ohio Trauma Registry. Click Here to return to the Table of Contents 8

9 Field # 4: Values: Zip Code of Residence The patient s five-digit zip code for place of residence, at the time of their injury. Enter for patients that reside outside of the USA. 1. Length 5 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). NUMERIC Field Instructions: Enter in the patients zip code number of their residence at the time of their injury. If patient is homeless, enter the zip code of the location of injury. Enter for patients that reside outside of the USA. Do not enter the 4-digit extension. Click Here to return to the Table of Contents 9

10 Field #5: Values: Patient s Date of Birth mmddyyyy Not documented 1. Length 8 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). DATE Field Instructions: The patient s date of birth. Enter the month, day and year of the patient s Date of Birth. If the patients age is known, but the date of birth is not, enter 01/01/YYYY (YYYY appropriate to patients known age) Entire year must be used Example: 1998 Enter in the patient s date of birth. Must use this format 01/01/1998. It is necessary to enter the year using the entire year. Click Here to return to the Table of Contents 10

11 Field #6: Values: Gender 1- Male 2- Female 3- ND (Not Documented) 1. Length 1 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). NUMERIC Field Instructions: The patient s gender at the injury date. Enter the patient s gender using the options available from code table above. Use the pulldown menu to select this field. Select the most appropriate option. Click Here to return to the Table of Contents 11

12 Field #7: Values: Race/Ethnicity 1- American Indian or Alaskan Native 2- Asian 3- Black, not of Hispanic origin 4- Hispanic or Latino 5- Native Hawaiian or Other Pacific Islander 6- White 7 Other 8 Multi-racial 9- ND (Not Documented) 1. Length 1 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). NUMERIC Field Instructions: The patient s race/ethnic group. Enter the patient s race from the available options. Use the pulldown menu to select this field. Select the most appropriate option. If more than one race value #1 to #6 is selected then value number 8 Multiracial must be selected. Note that pediatric facilities are limited to selection of only one value. Adult facilities can select multiple values, which will reported as 8 multi-racial. Values: 1- White 2- Black 3- Hispanic 4- Native American 5- Asian 6- Other 7- Multi-racial Click Here to return to the Table of Contents 12

13 Field #8: Values: Date of Onset (Date Injury Occurred) mmddyyyy ND (Not Documented) Unknown, if specifically documented as Unknown in the medical record. 1. Length 8 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). DATE Field Instructions: The date the injury occurred. Enter the month, day and year of the injury. The year must be 4-digits. Example: The date on which injury occurred must be the earliest date associated with the trauma event. All treatment dates must be equal to or after the date on which the injury occurred. Enter the patient s actual date of injury Click Here to return to the Table of Contents 13

14 Field #9: Values: Version 1.0 Effective January 1, 2005 Rehabilitation Admission From 1 Home 2 Board and Care 3 Transitional Living 4 Intermediate care 5 Skilled Nursing Facility 6 Acute Unit of own facility 7 Acute Unit another facility 8 - Chronic Hospital (LTAC) 9 Rehabilitation facility 10 Other 12 Alternate Level of care 13 Subacute setting 14 Assisted Living Residence 1. Length 2 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). NUMERIC Field Instructions: If # 4, 5, 7, or 9 is selected, field # 10 Transferring Facility ID must be competed. Value number 11 is purposefully not utilized for this field. Definitions Home: A private, community based dwelling (a house, apartment, mobile home, etc) that houses the patient, family, or friends. Board and Care: A community based setting where individuals have private space (either a room or apartment), or a structured retirement facility. The facility may provide transportation, laundry, and meals, but no nursing care. Transitional Living: A community based, supervised setting where individuals are taught skills so they can live independently in the community. Intermediate care (nursing home): A long term care setting that provides health related services but a registered nurse is not present 24 hours a day. Patients live by institutional rules; care is ordered by a physician, and a medical record is maintained. Patients in intermediate care are generally less disabled than those in skilled care facilities Skilled Nursing Facility (nursing home): A long term care setting that provides skilled nursing services. A registered nurse is present 24 hours a day. Patients live by institutional rules; care is ordered by a physician, and a medical record is maintained. Acute Unit of own Facility: An acute medical/surgical care unit in the same facility as the rehabilitation unit. Acute Unit another Facility: An acute medical/surgical care facility separate from the rehabilitation unit. Chronic Hospital (LTAC): A long-term care setting classified as a hospital, long term acute care. Rehabilitation facility: An inpatient setting that admits patients with specific disabilities and provides a team approach to comprehensive rehabilitation services, with a physiatrist (or physician of equivalent training/experience) as the physician of record. 14

15 Other: Used only if no other code is appropriate Alternate Level of care: Physically and fiscally distinct units that provides care to individuals who no longer meet acute care criteria Subacute setting: Subacute care is goal-oriented, comprehensive, inpatient care designed for an individual who has an acute illness, injury or exacerbation of a disease process. It is rendered immediately after, or instead of, acute hospitalization to treat one or more specific active, complex medical conditions an overall situation. Generally the condition of an individual receiving subacute care is such that the care does not depend heavily on high technology monitoring or complex diagnostic procedures. Subacute care requires the coordinated services of an interdisciplinary team, including physicians, nurses, and other relevant professional disciplines whoa re knowledgeable and trained to assess and manage specific conditions and perform the necessary procedures. Subacute care is given as part of a specially designed program, regardless of the site. Subacute care is generally more intensive than traditional nursing home care, but less than acute inpatient care. It requires frequent (daily to weekly) patient assessment and review of the clinical course and treatment plan for a limited time period (several days to several months), until a condition is stabilized or a predetermined course is completed. Assisted Living Residence: A community based setting that combines housing, private quarters, freedom of entry and exit, supportive services, personalized assistance, and healthcare designed to respond to individual needs of those who need help with activities of daily living and instrumental activities of daily living. Supportive services are available 24 hours a day to meet scheduled and unscheduled needs in a way that promotes maximum dignity and independence for each resident. These services involve the resident s family, neighbors, and friends. Click Here to return to the Table of Contents 15

16 Field #10: Pediatric Prehospital Setting Values: Version 1.0 Effective January 1, Home 02 Acute Care unit of own facility 03 Acute care unit of another facility 04 Rehabilitation facility 05 Residential facility 06 Transitional living center 07 - Skilled nursing facility 08 Shelter 09 Other 10 - Died 1. Length 2 2. Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Field Instructions: Select the value that most accurately describes the patients living arrangements prior to their hospitalization. Note the value 04 is not used in this field. Values: Click Here to return to the Table of Contents 16

17 Field #11: Pediatric Living With Values: 01 Two parents 02 One parent 03 - Relatives 04 Foster care 05 - Other 07 ND 1. Length 2 2. Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Version 1.0 Effective January 1, 2005 Field Instructions: Select a value in this field ONLY if the value selected in field # 10 Pediatric Prehospital Setting is equal to "01- Home" Click Here to return to the Table of Contents 17

18 Field #12: Pediatric Education Category Values: 01 Not a student 02 Early Intervention program 03 Preschool 04 Kindergarten through 12th 05 Other Version 1.0 Effective January 1, Length 2 2. Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character) NUMERIC Field Instructions: Select the value that best describes the patients educational category Click Here to return to the Table of Contents 18

19 Field #13: Pediatric Educational Setting Version 1.0 Effective January 1, 2005 Values: 01 Regular Class 02 Regular class with accommodation 03 Special Class 04 Home-based or Home Schooled 05 Day Care/nursery school/center-based/community 1. Length 2 2. Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Field Instructions: If value 2, 3 or 4 is selected for the Pediatric Education Category, then an appropriate value for this field must be reported. If 01 or 05 is selected for Pediatric Education Category, then 06- NA must be selected. Click Here to return to the Table of Contents 19

20 Field #14: Adult Prehospital Living With Values: 01 Alone 02 Family/Relatives 03 - Friends 04 Attendant 05 - Other 06 - ND 1. Length 2 2. Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Version 1.0 Effective January 1, 2005 Field Instructions: Select the value that most accurately describes the patients living arrangements prior to their hospitalization Click Here to return to the Table of Contents 20

21 Field #15: Adult Prehospital Vocational Category Values: 01 Employed 02 Sheltered 03 - Student 04 Homemaker 05 Not Working 06 Retired for Age 07 Retired for Disability 08 - ND 1. Length 2 2. Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character) NUMERIC. Field Instructions: Select the value that most accurately describes the patients vocation prior to their hospitalization DEFINITIONS Employed The patient works for pay in a competitive environment or is self employed Sheltered The patient works for pay in a non-competitive environment Student the patient is enrolled in an accredited school (including trade school), college or university. Homemaker The patient works at home, does not work outside the home, is not paid by an employer, and is not self employed Not Working The patient is unemployed, but is not retired or receiving disability benefits Retired for Age The patient is retired (usually 60 years of age or older) and is receiving retirement benefits Retired for Disability The patient is receiving disability benefits and is less than 60 years of age. Click Here to return to the Table of Contents 21

22 Field #16: Adult Prehospital Vocational Effort Values: 01 Full-time 02 Part-time 03 Adjusted Work load 04 NA 05 - ND 1. Length 2 2. Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Field Instructions: Select the value that most accurately describes the patients vocation prior to their hospitalization, if values 1 4 are selected in field # Prehospital Vocation Category, then are valid selections for this field. If are selected in field #, then 04 must be selected DEFINITIONS Full-time The patient worked a full schedule (i.e or 40 hours per week) which ever is normal where he/she works Part-time - The patient worked less than full time (i.e. less than 37.5 or 40 hours per week) depending on the norm where he/she works. Adjusted Workload The patients workload was adjusted due to disability. The patient was not able to perform all the work duties of the position Click Here to return to the Table of Contents 22

23 Field #17: Transferring Facility ID Values: ODH or ODPS assigned number. 1. Length 4 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). NUMERIC Version 1.0 Effective January 1, 2005 Field Instructions: If the patient is transferred from an Ohio hospital, enter the ODH assigned Ohio hospital code. See Appendix 2 for the list of ODH assigned Ohio hospital codes If the patient is transferred from an out of state hospital, enter the ODPS assigned out of state hospital code. See Appendix 3 for the list of ODPS assigned out of state hospital codes. If the patient is transferred from an Ohio Rehabilitation Facility, enter the ODPS assigned Ohio Rehabilitation Facility code. See Appendix 1 for the list of ODPS assigned Ohio Rehabilitation Facility codes If the patient is transferred from an Ohio Nursing Facility, enter the ODH assigned Ohio Nursing Facility code. See Appendix 4 for the list of ODH assigned Ohio Nursing Facility codes Click Here to return to the Table of Contents 23

24 Field #18: Rehabilitation Facility Arrival Date Values: mmddyyyy 1. Length 8 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character) DATE Field Instructions: The arrival date that the patient actually arrived at the rehabilitation facility. Enter the month, day and year. The actual date that the patient arrived at the rehabilitation facility. Date format: 01/29/1998. The year must be complete year (1998). Click Here to return to the Table of Contents 24

25 Field #19: Etiologic Diagnosis (ICD-9-CM Code) Values: Report the ICD-9-CM diagnosis codes 1. Length 5 2. Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Field Instructions: Use an ICD-9-CM code to indicate the etiologic problem that led to the condition for which the patient is receiving rehabilitation. These should be diagnosis codes, not external cause of injury codes. When creating a data file the decimal point MUST be used. Example: = or 810 = Give the complete code not category codes. Click Here to return to the Table of Contents 25

26 Field #20: Co-Morbid Conditions (ICD-9-CM Codes) Values: Report 10 additional ICD-9-CM codes of diagnoses 1. Length Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Field Instructions: The ICD-9-CM code for each injury diagnosis. List up to 10 codes. When creating a data file the decimal point MUST be used. Example: = or 810 = Click Here to return to the Table of Contents 26

27 Field #21: Complications during Rehabilitation Stay (ICD-9-CM Codes) Values: Report up to 6 ICD-9-CM codes 1. Length Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Field Instructions: Enter an ICD-9-CM code for each complication that began with this rehabilitation stay. List up to 6 codes. When creating a data file the decimal point MUST be used. Example: = or 810 = Click Here to return to the Table of Contents 27

28 Field # 22: Disability Assessment Tool Adult/Pediatric (FIM /WeeFIM instrument) Values: 1- Adult 2- Pediatric 1. Length 1 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character) NUMERIC. Field Instructions: Facilities using an adult assessment-scoring model (i.e. FIM TM instrument) should select 1 - Adult. Facilities that use a pediatric scoring model, (i.e. WeeFIM instrument) regardless of the patient's age should select 2 - Pediatric. The FIM instrument and the WeeFIM instrument incorporated or referenced herein are the property of UB Foundation Activities, Inc. 1993, 2001 (FIM Instrument) 1998, 2000 (WeeFIM instrument) UB Foundation Activities, Inc. The FIM and WeeFIM marks are owned by UB Foundation Activities, Inc. Click Here to return to the Table of Contents 28

29 Field #23: Disability Assessment Score upon Admission (FIM /WeeFIM instrument) Values: 0- Activity Does Not Occur (applies only to the FIM instrument) 1- Total Assistance 2- Maximum Assistance 3- Moderate Assistance 4- Minimal Assistance 5- Supervision / Set-up 6- Modified Independence 7- Complete independence 25 Self-Care: Eating 26 Self-Care: Grooming 27 Self-Care: Bathing 28 Self-Care: Dressing-Upper Body 29 Self Care: Dressing-Lower Body 30 Self-Care: Toileting 31 Sphincter Control: Bladder Management 32 Sphincter Control: Bowel Management 33 Transfers: Bed, Chair, Wheelchair 34 Transfers: Toilet 35 Transfers: Tub, Shower 36 Locomotion: Walk. Wheelchair, crawl 37 Locomotion: Stairs 38 Communication: Comprehension 39 Communication: Expression 40 Social Cognition: Social Interaction 41 Social Cognition: Problem Solving 42 Social Cognition: Memory Motor Subscore Cognitive subscore Total Motor and Cognitive score 1. Length Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character) NUMERIC. Field Instructions: Motor Subscore is a calculated field, the sum of fields #25 through #37 Cognitive Subscore is a calculated field; the sum of fields #38 through #42 Total Motor and Cognitive score is a calculated field, the sum of Motor subscore and Cognitive subscore Disability Assessment upon admission should be determined during the first three calendar days of the patients admission The FIM instrument and the WeeFIM instrument incorporated or referenced herein are the property of UB Foundation Activities, Inc. 1993, 2001 (FIM Instrument) 1998, 2000 (WeeFIM instrument) UB Foundation Activities, Inc. The FIM and WeeFIM marks are owned by UB Foundation Activities, Inc. Click Here to return to the Table of Contents 29

30 Field #24: Disability Assessment Score upon Discharge (FIM /WeeFIM instrument) Values: 1-Complete Dependence 2-Maximum assistance 3-Moderate Assistance 4-Minimal Assistance 5-Supervision / Set-up 6-Modified Independence 7-Complete independence 25 Self-Care: Eating 26 Self-Care: Grooming 27 Self-Care: Bathing 28 Self-Care: Dressing-Upper Body 29 Self Care: Dressing-Lower Body 30 Self-Care: Toileting 31 Sphincter Control: Bladder Management 32 Sphincter Control: Bowel Management 33 Transfers: Bed, Chair, Wheelchair 34 Transfers: Toilet 35 Transfers: Tub, Shower 36 Locomotion: Walk. Wheelchair, crawl 37 Locomotion: Stairs 38 Communication: Comprehension 39 Communication: Expression 40 Social Cognition: Social Interaction 41 Social Cognition: Problem Solving 42 Social Cognition: Memory Motor Subscore Cognitive subscore Total Motor and Cognitive score 1. Length Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). NUMERIC Field Instructions: Motor Subscore is a calculated field, the sum of fields #25 through #37 Cognitive Subscore is a calculated field; the sum of fields #38 through #42 Total Motor and cognitive score is a calculated field, the sum of Motor subscore and cognitive subscore The FIM instrument and the WeeFIM instrument incorporated or referenced herein are the property of UB Foundation Activities, Inc. 1993, 2001 (FIM Instrument) 1998, 2000 (WeeFIM instrument) UB Foundation Activities, Inc. The FIM and WeeFIM marks are owned by UB Foundation Activities, Inc. Click Here to return to the Table of Contents 30