Functional Independence Measure (FIM)

The Functional Independence Measure (FIM) Assessment Form provides a standardized instrument for evaluating the level of assistance required by patients to perform essential activities of daily living. It assesses 18 items across six functional domains — self-care (eating, grooming, bathing, dressing upper body, dressing lower body, toileting), sphincter control (bladder and bowel management), transfers (bed/chair/wheelchair, toilet, tub/shower), locomotion (walk/wheelchair, stairs), communication (comprehension, expression), and social cognition (social interaction, problem solving, memory). Each item is scored on a seven-level ordinal scale ranging from total assistance (1) to complete independence (7), producing both motor and cognitive subscale scores and a total FIM score.

This template captures the complete FIM instrument alongside contextual documentation that enhances clinical utility, including the patient's primary diagnosis, date of onset, admission source, expected discharge destination, and rehabilitation program goals. It records the assessment setting (admission, interim, or discharge) to support standardized outcome measurement across the rehabilitation continuum. A comparison section enables clinicians to view prior FIM scores alongside current scores, making functional gains immediately visible and facilitating data-driven treatment plan modifications.

Designed for inpatient rehabilitation facilities, skilled nursing facilities, outpatient rehabilitation programs, and long-term acute care hospitals, this form supports compliance with CMS Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) requirements. It provides the quantitative functional outcome data needed for quality reporting, reimbursement justification, program evaluation, and accreditation surveys, while giving rehabilitation teams an objective framework for measuring patient progress and demonstrating the effectiveness of interdisciplinary treatment interventions.