BRIEF INTERVIEW FOR MENTAL STATUS (BIMS)

1 BRIEF INTERVIEW FORMENTAL STATUS (BIMS)1234 NAME LastFirstMiddleAttending PhysicianRoom/BedRecord : INTERVIEW the resident using the guidance for BIMS INTERVIEW found in the MDS RAI User s Manual(Appendix D). Conduct the INTERVIEW in a private setting. Be sure the resident can hear you. Residents with hearingimpairments should be interviewed using their usual communication INTERVIEW FOR MENTAL STATUS (BIMS)ASSESSMENTA ssessment Reference Date (ARD) (if applicable) INTERVIEW DateRepetition of Three WordsNumber of words repeated after first Able to report correct by > 5 years or no by 2-5 by 1 resident: I am going to say three words for you to remember.

2 Please repeat the wordsafter I have said all three. The words are: sock, blue, and bed. Now tell me the three words. Temporal Orientation (orientation to year, month, and day)Ask resident: Please tell me what year it is right now. B. Able to report correct by > 1 month or no by 6 days to 1 within 5 daysAsk resident: What month are we in right now? C. Able to report correct day of the or no resident: What day of the week is today? After the resident s first attempt, repeat the words using cues ( sock, something to wear;blue, a color; bed, a piece of furniture ).

3 You may repeat the words two more SCOREAdd scores for questions and fill in total score (00-15)Enter 99 if the residentwas unable to complete the interview1234A. Able to recall sock - could not , after cueing ( something to wear ) , no cue requiredRecallAsk resident: Let s go back to an earlier question. What were those three words that I askedyou to repeat? If unable to remember a word, give cue (something to wear; a color; a pieceof furniture) for that Able to recall blue - could not , after cueing( a color ) , no cue requiredC.

4 Able to recall bed - could not , after cueing( a piece of furniture ) , no cue requiredForm 1890 PRev. 6/19 BRIGGS, Des Moines, IA (800) 247-2343 Unauthorized copying or use violates copyright law. INTERVIEW FOR MENTAL STATUS (BIMS) - STAFF ASSESSMENT1234 NAME LastFirstMiddleAttending PhysicianRoom/BedRecord the Staff Assessment for MENTAL STATUS be Conducted No- resident was able to complete the BRIEF INTERVIEW for MENTAL STATUS (BIMS) on front. Yes- resident was unable to complete the BRIEF INTERVIEW for MENTAL STATUS (BIMS) on INTERVIEW FOR MENTAL STATUS (BIMS) - STAFF ASSESSMENTASSESSMENTDateSeems or appears to recall after 5 minutes0.

5 Memory ok1. Memory problemSeems or appears to recall long past0. Memory ok1. Memory problemASSESSORSIGNATURE/TITLEASSMTASSMT ASSESSORSIGNATURE/TITLEBIMSSUMMARY SCOREAdd scores for questions and fill in total score (00-15)1234 Identify all the resident was normally able to recallA. Current seasonB. Location of own roomC. Staff names and facesD. That he/she is in a nursing home/hospital swing bedZ. None of the above were recalledMade decisions regarding tasks of daily life0. Independent - decisions consistent/reasonable1.

6 Modified independence - some difficulty in new situations only2. Moderately impaired - decisions poor; cues/supervision required3. Severely impaired - never/rarely made decisions_____ADDITIONAL COMMENTSS hort-Term MemoryLong-Term MemoryMemory/Recall AbilityCognitive Skills for Daily Decision Making