Conducting Functional Assessments

Required documents:

• Physician referral or order for evaluation
• Current medical records with diagnosis, surgical report if applicable, and medication list
• Prior therapy records or discharge summaries if available
• IRF-PAI form if inpatient rehabilitation admission assessment
• Insurance authorization or workers compensation claim number
• Any prior functional assessment reports for comparison

Step 1 — Select Appropriate Standardized Instruments

Match instruments to the clinical context and payer requirements:

Flag with [VERIFY] if the referral does not specify sufficient diagnostic information to select instruments.

Step 2 — Establish Prior Level of Function

Document PLOF across all relevant domains using patient/family interview:

• Self-care: Independent, supervision, or dependent for bathing, dressing (upper/lower), grooming, toileting, feeding
• Mobility: Ambulation distance and device (e.g., "household ambulator with rolling walker"), stairs, transfers
• Community function: Driving status, grocery shopping, meal preparation, work/school participation
• Cognitive-communication: Orientation, problem-solving for daily tasks, medication management

Use specific language: "Patient reports independent community ambulation without device for unlimited distances prior to CVA on 2024-02-15" rather than "patient was independent."

Step 3 — Administer FIM or Selected Primary Instrument

For the FIM (most common IRF instrument):

Motor subscale (13 items): Eating, grooming, bathing, dressing-upper, dressing-lower, toileting, bladder management, bowel management, bed/chair/wheelchair transfer, toilet transfer, tub/shower transfer, walk/wheelchair locomotion, stairs.

Cognitive subscale (5 items): Comprehension, expression, social interaction, problem solving, memory.

Scoring rules (7-point ordinal scale):

• 7 = Complete independence (timely, safely, no device)
• 6 = Modified independence (device, extra time, or safety concern)
• 5 = Supervision or setup (standby assist, cueing, coaxing)
• 4 = Minimal contact assist (patient performs ≥75% of effort)
• 3 = Moderate assist (patient performs 50-74% of effort)
• 2 = Maximal assist (patient performs 25-49% of effort)
• 1 = Total assist (patient performs <25% of effort)

Critical rules:

• Score what the patient actually does, not what they can do
• Score based on the most dependent performance in the assessment period
• "Helper" items (1-5) require documenting what the helper does
• For walk/wheelchair item, specify mode and distance (at least 150 feet for score of 6-7)

Step 4 — Administer Supplemental Balance and Mobility Measures

Berg Balance Scale (BBS): 14 items scored 0-4, maximum 56.

• Score <45 indicates fall risk and need for assistive device
• Score <36 indicates near 100% fall risk
• Minimal detectable change (MDC) = 5 points for stroke population

Timed Up and Go (TUG):

• <10 seconds = freely mobile
• 10-19 seconds = mostly independent
• 20-29 seconds = variable mobility, may need assistive device
• ≥30 seconds = impaired mobility, likely needs assistive device
• Record assistive device used and any observed deviations

6-Minute Walk Test (6MWT):

• Record distance in meters, rest breaks, vital signs pre/post, Borg RPE
• Age/sex normative values: healthy adults typically 400-700m
• Minimal clinically important difference (MCID): 50m for COPD, 50m for heart failure
• Document gait deviations, assistive device, supplemental O2

Step 5 — Document Activity Limitations Using ICF Framework

Structure findings using the International Classification of Functioning, Disability, and Health:

• Body functions/structures: Specific impairments identified (e.g., left hemiparesis, reduced LE ROM)
• Activity limitations: What the patient cannot do or does with difficulty (e.g., "unable to transfer sit-to-stand without moderate assist of one")
• Participation restrictions: Life roles affected (e.g., "unable to return to work as warehouse loader requiring repetitive lifting to 50 lbs")
• Environmental factors: Barriers or facilitators (e.g., "second-floor apartment without elevator, no caregiver at home")
• Personal factors: Age, comorbidities, motivation, prior experience with rehabilitation

Step 6 — Calculate Composite Scores and Compare to Benchmarks

• FIM total: Admission and discharge scores; calculate FIM gain and FIM efficiency (gain ÷ LOS)
• CMG (Case Mix Group): Determine based on impairment category, FIM motor score, FIM cognitive score, and age for IRF PPS
• National benchmarks: Compare scores to UDS (Uniform Data System for Medical Rehabilitation) national averages for the same impairment group
• Flag any scores that are inconsistent with clinical presentation as [VERIFY]

Checkpoint B — Pre-Finalization Review

Before finalizing the functional assessment report:

• All standardized instruments scored correctly with no blank items
• FIM scores reflect observed (not reported) performance
• PLOF documented with specificity (distance, device, assist level)
• Activity limitations linked to specific impairments
• Participation restrictions documented with real-world functional examples
• Scores compared against normative data or prior assessments
• Medical precautions that limited assessment noted
• Assessment signed and dated with evaluator credentials
• IRF-PAI Section GG completed if applicable

Quality Audit

• Each FIM item has a single numeric score (1-7) with no ranges
• Berg Balance Scale total computed correctly out of 56
• TUG time recorded in seconds with assistive device noted
• 6MWT distance in meters with vital signs and Borg RPE documented
• PLOF documented as specific functional descriptors, not "independent" alone
• All [VERIFY] flags resolved or escalated before final signature
• ICF framework categories addressed: body function, activity, participation, environment
• Instrument selection justified relative to diagnosis and setting
• Comparison to prior assessment included if reassessment
• Document meets facility, payer, and CARF documentation standards

Guidelines

• Use only standardized instruments with established reliability and validity for the target population
• Never extrapolate functional scores from observation alone when formal administration is possible
• FIM credentialing is required for scoring — verify evaluator has current FIM certification
• Do not use FIM scores interchangeably with Section GG items; they are different instruments
• APTA Guide to Physical Therapist Practice provides the framework for functional examination
• Document the specific edition and version of each instrument used
• When assessment is incomplete due to medical status, document reason and plan for completion
• For medicolegal FCEs, follow published protocols (e.g., Matheson, Isernhagen, ErgoScience) with consistency-of-effort measures
• All functional data is PHI — handle per HIPAA and facility privacy policies
• Escalate to the supervising physician if functional findings are inconsistent with the medical diagnosis