The WeeFIM II Clinical Guide Version 6

1 270 Northpointe Parkway, Suite 300, Amherst, New York 14228 tel: 716-817-7800 fax: 716-568-0037 2016 Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. FIM, The FIM System, WeeFIM , WeeFIM II, WeeFIMware, UDSMR, and the UDSMR logo are trademarks of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. Uniform Data System for Medical Rehabilitation The Functional Assessment Specialists The WeeFIM II Clinical Guide Version Prepared by: Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. 270 Northpointe Parkway, Suite 300, Amherst, New York 14228 Citation: Uniform Data System for Medical Rehabilitation. 2016. The WeeFIM II Clinical Guide , Version Buffalo: UDSMR. No part of this document may be modified, reproduced, stored in a retrieval system, transmitted in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise), or used to make any derivative work (such as translations and adaptations) without prior written permission from Uniform Data System for Medical Rehabilitation.

2 This Guide is for use beginning November 17, 2016. It replaces all previous versions of this Guide . Information in this document is subject to change without notice. All information contained in this document is accurate as of the date of publication (November 17, 2016). Address inquiries regarding copyright information to: Legal Services Uniform Data System for Medical Rehabilitation 270 Northpointe Parkway, Suite 300 Amherst, NY 14228 The WeeFIM II Clinical Guide Uniform Data System for Medical Rehabilitation, November 17, 2016 i The Functional Assessment Specialists Uniform Data System for Medical Rehabilitation Telephone Fax E-mail Web site Suite 300 270 Northpointe Parkway Amherst, NY 14228 Contents Section I: Introduction .. 1 Background .. 2 References .. 6 Acknowledgments .. 8 UDSMR Services .. 10 Sales and Client Services .. 10 Education and Training.

3 10 Credentialing .. 10 Data Management Service .. 10 Consultation .. 11 Research Services .. 11 Section II: Coding the Data Set .. 12 WeeFIM II Case Coding Form Instructions .. 13 Case Identification .. 13 Case Information .. 13 Patient Information .. 15 Patient Contact Information .. 15 Medical Information .. 16 Payer Information .. 17 Referral Information .. 17 Discharge Information .. 18 Resource Utilization .. 19 Surgeries .. 19 Custom Information .. 20 Impairment Group Codes .. 21 Stroke (01) .. 21 Brain Dysfunction (02) .. 21 Neurological Disorders (03) .. 21 Spinal Cord Dysfunction (04) .. 22 Amputations (05) .. 22 Arthritis (06) .. 23 Pain Syndromes (07) .. 23 Orthopaedic Conditions (08) .. 23 Cardiac Disorders (09) .. 23 Pulmonary Disorders (10) .. 23 Burns (11) .. 23 Congenital Disorders (12) .. 24 Other Disabling Impairments (13) .. 24 Major Multiple Trauma (14).

4 24 Developmental Disabilities (15) .. 25 Debility (16) .. 25 Failure to Thrive/Malnutrition (17) .. 25 The WeeFIM II Clinical Guide Uniform Data System for Medical Rehabilitation, November 17, 2016 ii The Functional Assessment Specialists Uniform Data System for Medical Rehabilitation Telephone Fax E-mail Web site Suite 300 270 Northpointe Parkway Amherst, NY 14228 Instructions for Coding Date of Onset for Each Impairment Group .. 26 Stroke .. 26 Brain Dysfunction .. 26 Neurological Disorders .. 26 Spinal Cord Dysfunction .. 26 Orthopaedic Conditions and Amputations .. 26 Major Multiple Trauma .. 27 Burns, Arthritis, and Pain Syndromes .. 27 Cardiac and Pulmonary Disorders .. 27 Developmental Disabilities .. 27 Cerebral Palsy .. 27 Spina Bifida .. 27 Congenital Disorders .. 28 Childhood Disorders with High Risk for Disabilities .. 28 Other Disabling Impairments5.

5 28 Program Interruptions Decision Tree .. 29 WeeFIM II Assessment Coding Form Instructions .. 30 Case Identification .. 30 Assessment Information .. 30 Custom Information .. 34 WeeFIM II Family-Centered Feedback Form Instructions .. 36 Case Identification .. 36 Patient Information .. 36 Patient Contact Information .. 36 Completion Information .. 37 Family-Centered Feedback .. 37 Return Contact Information .. 37 Section III: The WeeFIM Instrument .. 38 Underlying Principles for Use of the WeeFIM Instrument .. 39 General Rating Guidelines for the WeeFIM Instrument .. 41 General Level Descriptions for the WeeFIM Instrument .. 43 Instructions for Using the WeeFIM II Decision Trees .. 44 Generic WeeFIM II Decision Tree .. 45 Eating .. 46 Grooming .. 49 51 Dressing: Upper Body .. 54 Dressing: Lower Body .. 57 60 Bladder Management: Level of Assistance .. 62 Bladder Management: Frequency of Accidents.

6 65 Bowel Management: Level of Assistance .. 68 Bowel Management: Frequency of Accidents .. 71 Transfers: Chair, Wheelchair .. 73 Transfers: Toilet .. 76 The WeeFIM II Clinical Guide Uniform Data System for Medical Rehabilitation, November 17, 2016 iii The Functional Assessment Specialists Uniform Data System for Medical Rehabilitation Telephone Fax E-mail Web site Suite 300 270 Northpointe Parkway Amherst, NY 14228 Transfers: Tub, Shower .. 79 Locomotion: Walk, Wheelchair, Crawl .. 82 Locomotion: Stairs .. 89 Comprehension .. 92 Expression .. 95 Social Interaction .. 97 Problem Solving .. 100 Memory .. 102 Appendix A: Case Studies .. 104 Case Study: Joshua (Typical Development) .. 105 Answer Key: Joshua (Typical Development) .. 106 Case Study: Joseph (Developmental Delay) .. 109 Answer Key: Joseph (Developmental Delay) .. 110 Case Study: Brian (Traumatic Brain Injury).

7 113 Answer Key: Brian (Traumatic Brain Injury) .. 114 Appendix B: WeeFIM Normative Data .. 117 Appendix C: WeeFIM 123 Appendix D: Glossary .. 127 Appendix E: Frequently Asked Questions .. 133 General 134 Eating .. 136 Grooming .. 137 138 Dressing: Upper Body .. 139 Dressing: Lower Body .. 140 Dressing: Upper Body and Dressing: Lower Body .. 142 143 Bladder Management .. 144 Bowel Management .. 146 Transfers: Chair, Wheelchair .. 147 Transfers: Toilet .. 148 Transfers: Tub, Shower .. 149 Locomotion: Walk, Wheelchair, Crawl .. 150 Locomotion: Stairs .. 152 Comprehension .. 154 Expression .. 155 Social Interaction .. 156 Problem Solving .. 157 Memory .. 158 Appendix F: Blank Coding Forms .. 159 Case Coding Form .. 160 Assessment Coding Form .. 162 Family-Centered Feedback Form .. 163 Resource Utilization 164 Surgery Form .. 165 The WeeFIM II Clinical Guide Uniform Data System for Medical Rehabilitation, November 17, 2016 iv The Functional Assessment Specialists Uniform Data System for Medical Rehabilitation Telephone Fax E-mail Web site Suite 300 270 Northpointe Parkway Amherst, NY 14228 0 3 166 Appendix G: The 0 3 Module.

8 170 Domains and Items .. 171 Rating Scale .. 172 WeeFIM II Family-Centered 0 3 Form Instructions .. 173 Instructions for Page 1 .. 173 Instructions for Pages 2 4 .. 174 1 Section I: Introduction Section I: Introduction 2 Background The 1980s are generally thought of as the Golden Age of Rehabilitation. Inpatient rehabilitation units and hospitals were springing up everywhere. Length of stay and cost did not appear as deterrents to provision of a wide array of services. Shortages of allied health professionals cropped up all over the country; as the demand grew, so did their salaries. Over time, however, costs began to skyrocket as lengths of stay grew. Suddenly, rehabilitation clinicians found themselves having to justify their services and demonstrate outcomes of medical rehabilitation to internal stakeholders as well as third-party payers and accrediting bodies.

9 There was an increasing awareness on the part of these rehabilitation clinicians that they had no universally accepted, consistent terminology to communicate about disability, although many recognized the need, its potential value, and the difficulties of achieving uniformity. Then, in 1984, the Department of Education s National Institute on Disability and Rehabilitation Research (NIDRR) awarded a grant to the Department of Rehabilitation Medicine in the School of Medicine at the State University of New York at Buffalo to develop a system to document, in a uniform fashion, the severity of patient disability as well as the outcomes of medical A task force was charged with developing a uniform data set for adult inpatient medical rehabilitation. This task force, which consisted of the codirectors of the project in Buffalo (Dr. Granger and Dr. Hamilton) and representatives of the rehabilitation community nationwide, was sponsored by the American Congress of Rehabilitation Medicine (ACRM), the American Academy of Physical Medicine and Rehabilitation (AAPM&R), and eleven other national organizations concerned with medical rehabilitation.

10 The goal of the task force was to develop a functional assessment data set comprising the minimum number of items (minimal data set) that would be appropriate; that is, one that included only key functional attributes that were common and useful, discipline-free, and acceptable to clinicians, administrators, and researchers. The task force also had to create a rating scale to measure the items. Finally, the instrument had to be designed so that it could be administered quickly and uniformly, yet demonstrate validity and reliability. The resulting FIM instrument was intended to track patients from the initiation of hospital care through discharge and follow-up. Periodic reassessment would measure changes in patient performance to indicate progress toward independence primarily in personal care and mobility over time, while also providing data with which to measure rehabilitation program outcomes.