http://www.mediserve.com/blog/inpatient-rehab/testing-staffs-ability-to-recognize-key-words-infunctional-measurement-its-not-just-about-min-mod-max/
Blog Topic: August 26th 2012
LONG VERSION – Using key words to select & communicate appropriate functional measurement score
survey.
1. Occasional help to perform task. Patient provides most of effort.
4 = Minimally Dependent; No more than touching; patient expends >75% or more of effort
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2. Patient performs the task independently without devices or medications yet there are safety
concerns
6 = Modified Independence; > reasonable time, safety concern, > reasonable time, device
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Despite not knowing which of the 18 areas was being asked here, the key words are independent
without a helper and there are safety concerns. Page III-10 IRF-PAI Manual decision tree.
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“Does Patient need more than reasonable time or a device or is there a concern for safety?” IF YES = 6.
16/18 Agree
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3. Patient performs all effort while staff cues and coaxes completion.
5 = Supervision, Set Up; Stand-by, cuing, coaxing, no physical assistance; may apply device
 The key words are patient performs effort. Staff = helper that cues & coaxes ONLY.
 IRF-PAI Manual 2012, page III-10. “Does Patient need setup or supervision, cuing or coaxing
only?” Yes = 5
 It’s important for staff to ‘hold’ back initially to see if the patient can perform activities without
cueing & coaxing. When aides provide most of the bedside care to patients, it critical to teach
them to hold back when possible so that you can demonstrate the patients greatest independence.
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4. Requires more than occasional help with the caregiver providing hand over hand assistance
for every portion of the performed activity.
1 = Totally Dependent; Patient expends less than 25% of effort; Caregiver performs tasks.
2 = Maximally Dependent: Physically assist patient; patient expends between 25 - 49% of effort?
 If a caregiver is providing hand-over-hand for every portion of the activity, the caregiver is essentially
performing the activity for the patient in this description. It’s tricky because there are three different
key word concepts making it hard to decide. >occasional might suggest a 3 BUT hand over hand,
every portion immediately signals it’s way more than 50% and every portion required assistance.
 “Does Patient need total assistance?” Yes = 1 Page III-10 IRF-PAI Manual
 This requires clinical judgment and dependent on the real patient effort, it could border a 2!
 Even though I did not describe this as ‘grooming’, the prompt for a 1 in grooming asks,
“Does Patient require total assistance for grooming such as the helper holding the grooming items
and performing basically all the activities? If YES = 1 III-14 IRF-PAI manual 2012.
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Obviously this concept needs discussed in the clinics. What is the ‘burden of care’ for hand over hand assistance?
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5. An assessment for this task was recorded earlier, I need to assist the patient quickly to
perform this activity and do not have time to let them show me how much they can do for
themselves at this moment.
Not Observed - no assessment rendered / cannot score
 When there is no intention to assess the patient on their performance of an activity it is not fair to
‘score’ how much help was provided. Staff are clearly placed in this situation every day, yet at times
an aide or caregiver will describe how much help they provided and could place a “facility imposed”
conditional score. Does the patient assume a low score because staff is rushed? It’s better to NOT
observe or score. IRF-PAI Manual 2012, III-5 “Note: The patient's score on measures of function
should not reflect arbitrary limitations or circumstances imposed by the facility.”
 Respondents agree!
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6. This is not a cognitive area; the patient cannot perform the task I am requesting as it is
physically unsafe for the Admission Assessment Reference period timeline.
0 = Does Not Occur
 IRF-PAI Manual 2012 page III-6. During the assessment reference you must provide a score.
By indicating the patient cannot perform the activity a zero is appropriate.
 “A code of 0 may be used for some FIM items and some Function Modifiers to indicate that
the activity does not occur at any time during the assessment period.” “A code of 0 means that
the patient does not perform the activity and a helper does not perform the activity for the
patient, at any time during the assessment period.” “The patient does not attempt the activity
because the clinician determines that it is unsafe for the patient to perform the activity.”
 “Prior to recording a code of 0, the clinician completing the assessment must consult with
other clinicians, the patient's medical record, the patient, and the patient's family members to
determine whether the patient did perform or was observed performing the activity. Do not
use code "0" to indicate that the clinician did not observe the patient performing the activity;
use the code only when the activity did not occur.” Pg. III-7
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7. It is within the discharge reference window, the activity has nothing to do with locomotion or
tub transfers and the patient still is not able to perform the activity due to safety reasons. How is
this scored?
1 = Totally Dependent; Patient expends less than 25% of effort; Caregiver performs tasks
 *If activity does not occur at discharge, code FIM items using "1" III-6 & III-8; IRFPAI Manual
2012.
 “If a FIM activity does not occur at the time of discharge record a score of 1 – Total Assistance. If
a patient expires while in the rehabilitation facility, record a score of Level 1 for all discharge FIM
items.
 *If activity does not occur at discharge, code FIM items using "1".
 Pay attention to table on III-8. ‘Overview for use of code 0.’
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8. This patient requires occasional contact for balance; the activity requires three areas for
assessment and the patient only performs one of those items independently without significant
help of the caregiver.
2 = Maximally Dependent: Physically assist patient; patient expends between 25 - 49% of effort?
1 = Totally Dependent; Patient expends less than 25% of effort; Caregiver performs tasks?
 If an item REQUIRES 3 areas, then each are 33.3% of a total. Since the patient only performs one
independently, they cannot get greater than 33%. This excludes the ability to choose a 3 or a 4 since
both require the patient to perform greater than 50% of an effort. The ‘occasional contact’ for
balance was put in to confuse the real amount of help.
 Since there is ‘significant’ help in the other two areas, it is a clinical judgment as to whether the
patient expends > than 25% of the effort to determine a 2 or a 1; either would be acceptable.
 Often we give the patient the benefit of a doubt; you can see here most have chosen 2! Would you?
 This question needs discussed in the clinic! A larger sample shows this is a tough one for staff!
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9. The patient has an ostomy device; yesterday I read that the patient was independent after the
staff set up the equipment. Today the patient sets up their own equipment and no cuing was
provided during bowel management.
6 = Modified Independence; > reasonable time, safety concern, > reasonable time, device
 No helper; used a device for bowel management
 “If the individual has a colostomy, (s)he maintains it.” = 6. Page III-29 IRF-PAI Manual 2012.
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10. The patient uses a wheelchair and is ready to transfer back to bed. They manage to lock their brakes, remove
leg rests and arm rest independently. I place the transfer board under the patient by shifting their weight and
holding them so they do not fall. For each scoot over the board I assist the patient to reduce friction because
they cannot scoot unless I lift them. They cannot stand pivot yet. Once they are in the bed they can pull their legs
up onto the bed.
1 = Totally Dependent; Patient expends less than 25% of effort; Caregiver performs tasks. ?
2 = Maximally Dependent: Physically assist patient; patient expends between 25 - 49% of effort?
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IRF-PAI Manual 2012; page III-34.“Includes all aspects of transferring from bed to a chair, or wheelchair” “If in a
wheelchair, approaches a bed or chair, locks brakes, lifts foot rests, removes arm rests if necessary”
“Does Patient need only incidental help such as contact guarding or steadying during bed, chair, and wheelchair
transfers?” You can only get a 4 if this statement is YES. Therefore it is not a 4.
Since the patient needs a transfer board and they cannot perform the transfer UNLESS the caregiver lifts & scoots, the
caregiver performs more than 50% of the effort. In the decision tree in the manual, despite the patient managing the
wheelchair, it seems the LIFTING holds most of the decisional weight!
“Does Patient require total assistance for bed, chair, wheelchair transfers such as the helper doing basically all the
lifting or use of a mechanical lift?” IF YOU ANSWER YES to that question, the manual = 1. Only 4 people aligned
with the manual on this question. Since the patient is at wheelchair level and they manage that aspect, 25% pt. effort
is conceivable. The transfer is the ‘burden of care’ that is being heavily considered in the decision tree.
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11. The patient is in a wheelchair that is considerably higher than the toilet. S/he approach safely,
locks the brakes and removes the leg rests with minimal cuing. S/he transfers to the toilet with
contact guard. They are unable to get up from the toilet despite the use of toilet grab bars
requiring a full lift back to the wheelchair.
3 = Moderately Dependent: More help than touching; patient expends between 50 - 74% of effort
 Toilet Transfers:” includes safely getting on and off a standard toilet.” “If in a wheelchair, patient
approaches toilet, locks brakes, lifts foot rests, removes arm rests if necessary, and does either a
standing pivot or sliding transfer (without a board) and returns.” IRF-PAI Manual 2012; page III-36.
 “Does Patient need only incidental help such as contact guarding or steadying during toilet transfers?” In
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order to score a 4, one has to provide only incidental help; in this case the patient was lifted back.
Patient performed >50% (Transferred one way) & performed all w/c related activity independently= 3.
Given a therapist’s discretion, it is possible that a 2 could be the answer; most persons taking this survey
felt so. Five persons indicated a score of 1, they believed I suppose that the patient did less than 25% of
the effort.
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12. It requires two persons to safely ambulate the patient for any amount of distance.
1 = Totally Dependent; Patient expends less than 25% of effort; Caregiver performs tasks
 “Does Patient walk less than 50 feet (15 m) or is the assistance of two persons required for
ambulation?” If YES = 1 IRF-PAI Manual 2012; page III-42. Excellent agreement by survey.
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13. The patient can propel their wheelchair without any help household distances of 55 feet.
5 = Supervision, Set Up; Stand-by, cuing, coaxing, no physical assistance; may apply device
 Exception (Household Locomotion—The patient operates a manual or motorized wheelchair independently
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only short distances (a minimum of 50 feet) or 17 meters. (Page III-43 lists 15 meters, page III-44 list 17
meters, however the distance in feet is consistent!  ).
IRF-PAI Manual 2012; page III-44
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14. The patient ambulates up and down 10 steps and requires the help of two persons.
1 = Totally Dependent; Patient expends less than 25% of effort; Caregiver performs tasks
 “ Total Assistance—The patient performs less than 25% of the effort, or requires the assistance of
two people, or goes up and down fewer than 4 stairs.” = 1. IRF-PAI Manual 2012; page III-45
 Several ‘or’ requirements. A flight of stairs is considered 12-14 steps but when two persons are
required to safely perform this activity it automatically defaults to a 1.
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15. It is not safe to take the patient on the stairs anytime within the first three days of their IRF
stay.
0 = Does Not Occur
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IRF-PAI Manual 2012 page III-6. During the assessment reference you must provide a score. By
indicating the patient cannot perform the activity a zero is appropriate.
“A code of 0 may be used for some FIM items and some Function Modifiers to indicate that the
activity does not occur at any time during the assessment period.” “A code of 0 means that the patient
does not perform the activity and a helper does not perform the activity for the patient, at any time
during the assessment period.” “The patient does not attempt the activity because the clinician
determines that it is unsafe for the patient to perform the activity.”
“Prior to recording a code of 0, the clinician completing the assessment must consult with other
clinicians, the patient's medical record, the patient, and the patient's family members to determine
whether the patient did perform or was observed performing the activity. Do not use code "0" to
indicate that the clinician did not observe the patient performing the activity; use the code only
when the activity did not occur.” Pg. III-7 Excellent agreement for this question.
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16. The patient ambulates up and down 12 steps with the help of one person. The patient
requires contact guard and an occasional placement of the foot on the step if a scissoring is
noticed when placing their foot on the next step.
3 = Moderately Dependent: More help than touching; patient expends between 50 - 74% of effort
 “Does patient need only incidental help such as contact guarding or steadying to go up and down 12 to
14 stairs?” If yes = 4. Placement of foot exceeded the 4 definition. Steadying is a level 4, but placing a
foot is more than ‘touching’ to steady. Enough persons in the larger sample survey disagreed with this
assessment; making this is a good question to review with staff for accuracy. Clearly the patient
expended >50% of the effort as only some physical assistance other than contact was required. IRF-PAI
Manual 2012; page III-46.
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17. After the utensils are placed in the patients hand (toothbrush, hair brush, washcloth), the
patient requires the caregiver to help hand over hand (to keep utensils in the hand) and then
assists in the necessary movements to complete each of the tasks for grooming.
1 = Totally Dependent; Patient expends less than 25% of effort; Caregiver performs tasks
 If a caregiver is providing hand-over-hand for every portion of the activity, the caregiver is
essentially performing the activity for the patient. Hand over hand, to complete each of the tasks
signals the patient does less than 25% independently. The patient cannot groom without a
caregiver.
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The prompt for a 1 in grooming asks, “Does Patient require total assistance for grooming such as
the helper holding the grooming items and performing basically all the activities? If YES = 1 IRFPAI Manual 2012; page III-14. Obviously this concept needs discussed in the clinics because more
people selected an answer that does not agree with the manual branching logic. What do your
staff think?
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18. The patient requires incidental physical help with only one area of grooming because they
became too tired to complete all tasks independently.
4 = Minimally Dependent; No more than touching; patient expends >75% or more of effort
 “Does Patient need only incidental help such as placement of a washcloth in his/her hand or help to
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perform just one of the several tasks included in grooming? “ Yes=4. IRF PAI Manual III-14 )
Minimal of 4 areas need answered, one area required ‘incidental help’; patient performed 75% or more.
100% agreement in the survey.
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19. The patient approaches the sink independently at wheelchair level; as expected supplies
were within reach on the sink and S/he performed the task independently and timely.
6 = Modified Independence; > reasonable time, safety concern, > reasonable time, device
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This item includes obtaining articles necessary for grooming. If the patient required the w/c to
approach the sink independently it would be considered a ‘device’ since ‘obtaining articles is part of
the assessment. (Tricky) IRF PAI Manual III-13)
If the patient could walk to the sink, a score of 7 is achieved. This is not spelled out but implied. Do
you agree? Clinical judgment prevails on this one; you could debate a 7 but if the patient cannot
access the items independently without the wheelchair, one would argue the wheelchair is a device
that enables independence.
In the previous IRF-PAI manual on page H-7, it stated that if a caregiver ‘brought’ supplies to the
patient out of need, ‘supervision or set-up’ and a score of 5 is applied. You have to know if the
patient CAN retrieve their supplies to really answer this one earnestly.
20. The patient requires physical assistance for washing, rinsing and drying the body for more
than two areas of the body, in fact, the caregiver must hold the washcloth or towel most of the
time since grasp is weak.
2 = Maximally Dependent: Physically assist patient; patient expends between 25 - 49% of effort
1 = Totally Dependent; Patient expends less than 25% of effort; Caregiver performs tasks
 “Does Patient need only incidental help such as placement of washcloth in his/her hand a few times as
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s/he bathes or help to bathe just one or two areas of the body, such as one limb, or the feet or the
buttocks? “ IF YES =4. It cannot be a 4 since it says MORE THAN two areas. IRF-PAI Manual 2012; page
III-16.
“Does Patient require total assistance for bathing such as the helper holding the washcloth and towel
and performing basically all the activities?” IF YES = 1, if NO=2. NOT every time but most of the time
the care giver is holding the washcloth and towel because ‘grasp is weak’. The clinician must decide if
they assisted >25% of the time to make this decision! Either seems feasible. Both large & small
samples are very similar in results when surveyed.
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21. The patient is bathing and with just cues has performed all of the washing, rinsing and drying
of all body parts. A few times, the patient required the caregiver to place the washcloth or towel
back in their hand after dropping it out of their safe reach.
4 = Minimal Independence; No more than touching; patient expends >75% or more of effort OR
5 = Supervision, Set Up; Stand-by, cuing, coaxing, no physical assistance; may apply device
 If you went strictly by the guide, helper or no helper, it did require a helper ‘a few times’. Clinical
judgment might argue different if you look at the near split responses of those surveyed. IRF-PAI
Manual 2012; page III-16.
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22. The patient is dressing their upper body and requires help to hold the clothing so they can
place their head into the opening and maneuver their arms through the sleeves. The patient can
button and snap their own fasteners on their shirt.
2 = Maximally Dependent: Physically assist patient; patient expends between 25 - 49% of effort
1 = Totally Dependent; Patient expends less than 25% of effort; Caregiver performs tasks
 “Does Patient need only incidental help such as help to initiate dressing above the waist or assistance
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with buttons, zippers or snaps only?” If yes =4. This helper has to ‘hold the clothing’ to enable upper
body dressing. Most people surveyed missed the key words of ‘holding’ rather than help to ‘initiate’.
If a helper holds the clothing then you go left in the decision tree to a 1 or 2 response score. This
clearly needs discussed in the clinic.
“Does Patient require total assistance for dressing above the waist such as the helper holding clothing
and performing basically all the activities?” If holding clothing and assisting limbs the score is a 1, if
the helper is holding the clothing and they feel the patient has done more than 25% of the effort then
a 2 could be scored. This is again a clinical judgment but it requires more than ‘incidental’ assistance.
IRF PAI Manual 2012; page III-19.
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23. With the placement of a tenodesis wrist splint, the patient can dress their upper body
independently, including buttoning and fastening the clothing
6 = Modified Independence; > reasonable time, safety concern, > reasonable time, device
5 = Supervision, Set Up; Stand-by, cuing, coaxing, no physical assistance; may apply device
 IRF-PAI Manual 2012; page III-19. Dresses upper body independently with use of a device.
Since it did not DESIGNATE WHO applied the device, either a 5 or 6 is appropriate. IF the
patient applied the device =6. If a helper applied the device =5.
 Both the small and larger sample spread that answer equally, giving a slight edge to the
benefit of a doubt that the patient applied their own tenodesis splint.
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24. The family has not brought in the patients clothing, I suggest to the patient that we try to take
on and off scrub pants but the patient refuses. S/he prefers to use their own clothing when they
get dressed.
0 = Does Not Occur would be scored in the assessment reference period and is the most feasible
answer.
1 = Totally Dependent; Patient expends less than 25% of effort; Caregiver performs tasks (If it was in
the discharge window and the patient refused to participate in a dressing assessment.) If still refusing
instead of a zero a 1 is given at discharge.
Not Observed - no assessment rendered
 The patient refuses to perform an activity (e.g., the patient refuses to dress in clothing other than a
hospital gown or the patient refuses to be dressed by a helper). “Putting on and taking off scrubs
may be appropriate for purposes of assessment.” If the patient refuses, it is scored as does not
occur and the best effort to obtain clothes appropriate to wear in public. Use of zero should be
rare but if this is the ASSESSMENT reference period you must have a score and zero would be
appropriate. IRF PAI Manual 2012; page III-6, III-17 & 18.
 Since it did not stipulate if this was in the assessment period, interim stay or in a discharge
window timeframe, it is feasible that 0, Not observed and 1 are all POSSIBLE considerations. !!!
The content suggests it’s early in the stay but it’s not specifically stated. Kudos to staffs that
debate this one.
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25. The patient is lying in bed to perform the lower body dressing task because their balance is
not yet safe to sit at the edge. The patient is able to hold their own pants but the caregiver must
lift their legs to help thread them through the pant legs. The patient can roll from side to side and
is able to pull the clothing over their own hips as well as fasten the closures. They can put on
their own socks and shoes using assistive devices for reach.
2 = Maximally Dependent: Physically assist patient; patient expends between 25 - 49% of effort
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POSITION IS NOT considered; ability to retrieve own clothes from a customary place is.
“Does Patient perform half or more of the lower body dressing tasks?” This is the main question when
considering ‘lifting & threading’ legs through pants for the patient. IRF-PAI Manual 2012; page III-22.
Because it requires a helper to ‘lift both legs and thread them through the clothing’, this effort is greater
than 50% of the dressing task for lower body. If the information stated the patient could use devices to
accomplish that independently the answer could be a 6 !
In the old IRF-PAI Manual, page H-15, there was an example where the patient rolled from side to side
while a caregiver ‘pulled up’ the clothing for the patient and that was considered a ‘1’ level of assistance.
I do not believe that given the scenario above that ANY of the responses provide by persons taking the
survey reflect the burden of care for the amount of assistance to lift both legs and to thread them
through the pants for the patient. As a clinician, how would you assess this effort?
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26. The patient uses a reacher and long handled shoe horn to dress the lower body. They are
safe and perform the activity in a reasonable amount of time.
6 = Modified Independence; > reasonable time, safety concern, > reasonable time, device
 IRF-PAI Manual 2012; page III-22. Excellent agreement.
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27. The patient can hold their own clothing but lacks stabilization to thread their legs into their
under pants and pants. The caregiver lifts the patient’s legs. The patient needs the same amount
of help with their feet while the patient helps hold their socks open. The caregiver places the
shoes in a location where the patient can slide their feet into the shoes and then the patient can
tie them, needing help to sit back up in the chair.
1 = Totally Dependent; Patient expends less than 25% of effort; Caregiver performs tasks
 The clinician expends more than 75% of the effort. This is very similar to question 25 except that clearly
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the clinician is assisting with even more areas/items.
In the old IRF-PAI Manual, page H-15, there was an example where the patient rolled from side to side
while a caregiver ‘pulled up’ the clothing for the patient and that was considered a ‘1’ level of
assistance. I do not believe that given the scenario above that ANY of the responses provide by
persons taking the survey reflect the burden of care for the amount of assistance to lift both legs and
to thread them through the pants for the patient. As a clinician, how would you assess this effort? Is
the patient ‘safe’ if they cannot sit back up during this activity? Lacking stabilization and the inability to
sit back up paints the picture of a very dependent patient. These types of scenarios need discussed in
the clinic.
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28. The facility leaves a bedside commode next to every patient’s bed for convenience at night.
The patient controls bowels completely and intentionally without any noted accidents for more
than 3 days, but since the bedside commode is present they use it at night even though they
could go to the bathroom but staff like the convenience.
Not Observed - no assessment rendered / cannot score
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The scenario does not really tell you if you are scoring bladder or bowel accidents, bladder or bowel management,
toileting or toilet transfers. Regrettably it was a bad question but often staffs speak to each other in a similar way
without giving all the information and or scoring without considering information that needs considered to apply a
score; this is especially true when aides relay ‘accident’ information to another caregiver to score for them.
If it was accidents – there were NONE for bowel, we do not know about bladder.
Under accidents (still considering devices), we know the patient has a commode but it states it is for staff
convenience rather than patient necessity. This patient may warrant a 7 for bowel accidents if you consider all these
factors but you don’t know if they take stool softeners or other medications; you can’t really give them a 7 either!
You cannot score bladder accidents or management questions, you don’t have enough information!
We don’t know if the patient wears pads or is taking any kind of medication for either bowel or bladder.
Staff convenience – facility imposed restrictions? You do not have enough information to score ‘toileting’ because
there is nothing that tells you how much help is required to manage clothing and perform hygiene. You don’t have
enough information for toilet transfers either. You only know the patient can ‘go to the bathroom’. When you have
this much information and no ability to fill in the gaps; DON’T ASSESS, do not score!
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29. The patient has had a total of 3 bladder accidents in the past 7 days. (Soiling of linen or
clothing requiring a change.) Considering only the number of accidents, what score is applied for
accidents? (The PAI will eventually utilize the lowest score between management and accident to
reflect burden).
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Three (3) accidents, including bedpan and urinal spills, in the past 7 days = 3
If a patient utilized medication, this would only be considered if the patient had no accidents.
This area needs addressed with staff because the responses in the survey indicate there is still confusion
around counting ‘accidents’.
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30. The patient requires continual prompting to communicate basic needs and does not seem to
understand or responds inappropriately when asked questions about basic needs for
comprehension.
1 = Total Assistance—The patient understands directions and conversation about basic daily needs less
than 25% of the time, or does not understand simple, commonly used spoken expressions (e.g., hello,
how are you) or gestures (e.g., waving good-bye, thank you), or does not respond appropriately or
consistently despite prompting
 IRF-PAI Manual 2012; page III-48. Excellent agreement in the survey responses.
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31. The patient needs help to understand directions and conversation about basic needs only
occasionally. Very little prompting is necessary for comprehension.
5 = Standby Prompting—The patient understands directions and conversation about basic daily needs
more than 90% of the time. The patient requires prompting (slowed speech rate, use of repetition, stressing
particular words or phrases, pauses, visual or gestural cues) less than 10% of the time.
 “Does Patient need help to understand directions and conversation about basic daily needs only rarely
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(less than 10% of the time)?” IRF-PAI Manual 2012; page III-48.
Even though the key words said occasionally, it clarified this to mean ‘very little’. Very little is probably
10% or less. In order to score a 4 it requires up to 25% of the time to prompt for comprehension.
The percent of prompting for basic needs comprehension should be reviewed. Despite the answer being
present in the drop downs using very similar words to assess, this topic leaned nearly half & half between
4 & 5. Since this assistance is generally verbal …when occasional/rare it is similar to CUEING! (Easier to
remember what level when you think this way!
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32. The patient needs help to express basic needs of hunger, thirst or discomfort only rarely.
5 = Standby Prompting. The patient expresses basic daily needs and ideas more than 90% of the time.
Requires prompting (e.g., frequent repetition) less than 10% of the time to be understood.
 IRF=PAI Manual 2012; page III-50.
 Help to express needs only rarely is within 10% of the time. Stand-by prompting is another way
this is described. Ten persons assessed according to the manual guidelines leaving another 5 to
select up to 4 other scores.
 This area needs reviewed with staff to discern % of prompting or help needed to express basic
needs. Associate ‘rare & occasional’ with ‘cueing’ comprehension and staff will get this correct.
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33. The patient is unable to express discomfort, hunger, thirst or expresses these inappropriately
or inconsistently when prompted most of the time.
1 = Total Assistance. The patient expresses basic daily needs and ideas less than 25% of the time, or does
not express basic needs appropriately or consistently despite prompting.
 IRF-PAI Manual 2012; page III-49 & 50.
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34. The patient needs extra time in social situations and to interact appropriately with staff. They
do well in structured or modified environments and take medication for anxiety and depression.
6 = Modified Independence—The patient interacts appropriately with staff, other patients, and family members in most
situations, and only occasionally loses control. The patient does not require supervision, but may require more than a
reasonable amount of time to adjust to social situations, or may require medication for control.
35. The patient needs help to interact appropriately with others only on occasion.
4 = Minimal Direction—The patient interacts appropriately 75 to 90% of the time.
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“Does Patient need help to interact appropriately with others only occasionally (less than 25% of the time)?” If
YES =4.
IRF-PAI Manual 2012; page III-52.
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36. The patient does not need any help or medications to interact with others in social and
therapeutic situations.
7 = Complete Independence—The patient interacts appropriately with staff, other patients, and family
members (e.g., controls temper, accepts criticism, is aware that words and actions have an impact on others),
and does not require medication for control.
 IRF=PAI Manual 2012; pages III-51 & 52. 100% agreement with those answered the survey.
37. The patient does not need extra time to make decision or solve problems, they can selfcorrect and make decisions in familiar and unfamiliar situations.
7 = Complete Independence—The patient consistently recognizes problems when present, makes appropriate
decisions, initiates and carries out a sequence of steps to solve complex problems until the task is completed,
and self-corrects if errors are made.
 IRF-PAI Manual 2012: page III-53 & 54.
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38. The patient needs help to solve problems most of the time as they are unable to solve
problems or are very inconsistent. Generally, to be safe they require supervision.
1 = Total Assistance—The patient solves routine problems less than 25% of the time. The patient needs
direction nearly all the time, or does not effectively solve problems, and may require constant one-to-one
direction to complete simple daily activities. The patient may need a restraint for safety.
 IRF-PAI Manual 2012; page III- 53 & 54.
39. The patient requires minimal prompting to recognize people or daily routines. Generally you
do not have to repeat request and the patient self-initiates or uses environmental cues to recall
day to day activities.
4 = Minimal Prompting. The patient recognizes and remembers 75 to 90% of the time.
 MEMORY – “Does Patient need help to recognize and remember only occasionally?” IRF-PAI
MANUAL 2012; page III-56
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40. The patient needs help to recognize and remember only rarely or under stressful conditions.
5 = Supervision. The patient requires prompting (e.g., cuing, repetition, reminders) only under stressful
or unfamiliar conditions, but no more than 10% of the time.
 “Does Patient need help to recognize and remember only rarely or only under stressful
conditions?” YES = 5 IRF-PAI MANUAL 2012; page III-56
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LONG VERSION KEY:
1. 4
11. 3
21.
4 or 5
31.
5
2. 6
12. 1
22.
2 or 1
32.
5
3. 5
13. 5
23.
6 or 5
33.
1
4. 1 or 2
14. 1
24.
Zero,1 or Not Obs.
34.
6
5. Not Obs
15. Zero
25.
2
35.
4
6. Zero
16. 3
26.
6
36.
7
7. 1
17. 1
27.
1
37.
7
8. 2 or 1
18. 4
28.
Not Obs.
38.
1
9. 6
19. 6
29.
3
39.
4
10. 1 or 2
20. 2 or 1
30.
1
40.
5
The purpose of this exercise is to assist staff in paying attention to the subtle key words used in the IRF-PAI manual
decision trees when scoring functional assessment. Given the information provided, staff may answer the question in
one of several ways and should be able to discuss why they made one choice over another. By sharing with you the
prevalence of how others read and scored the exercise it provides some insight to the fact that scores can be ‘all over
the place’ if specific decision elements are not provided and if staff do not pay attention to the greatest burden
elements if there is a combination of descriptions provided. Ask staff to choose the BEST ANSWER given the
information available.
IRF-PAI manual reference pages are provided along with some discussion as to what might be the best answer.
Sometimes clinical judgment takes precedence to weigh between two scores. Because we made a short and long
version of this exercise available, whenever the same question was asked to the full set of respondents you can look at
BOTH sets of answers. Respondents were not asked to describe anything about their background or experience.
We hope you find this helpful as another way to educate and provide clinical discussion around the importance of
scoring. Several point swing shifts can make huge differences in baseline resource allocation as it relates to the CMI
and payment for your Medicare populations. Because outcomes are driven by pre/post answer changes, you want to
be certain that staff think critically before applying measurement scores.
Cordially,
Darlene L. D’Altorio-Jones, PT., MBA-HCM
Strategist, Rehabilitation Management
MediServe
09.07.2012
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Questions:
LONG
VERSION
Questions:
SHORT
VERSION
Agreement
With
Discussion
Number
Respondents to
that Question
% Agreement ALL
Questions
Combined
% Agreement
Abbreviated # of
Questions Answered
1
1
48
56
85.7%
85.7%
16
18
88.9%
2
3
2
56
56
100.0%
100.0%
4
3
33
56
58.9%
58.9%
5
4
47
52
90.4%
90.4%
6
11
18
61.1%
7
9
18
50.0%
33
54
61.1%
14
16
87.5%
6
29
52
55.8%
3
17
17.6%
7
15
17
88.2%
9
17
52.9%
8
5
9
10
11
12
W13
61.1%
55.8%
88.2%
14
8
37
53
69.8%
69.8%
15
9
42
53
79.2%
79.2%
16
10
23
53
43.4%
43.4%
17
11
19
53
35.8%
35.8%
17
17
100.0%
18
19
12
15
53
28.3%
28.3%
20
13
46
52
88.5%
88.5%
21
14
48
50
96.0%
96.0%
3
15
20.0%
47
50
94.0%
24
15
15
100.0%
25
0
15
0.0%
16
47
49
95.9%
0
14
0.0%
17
10
49
20.4%
8
15
53.3%
22
23
26
15
27
28
29
94.0%
95.9%
20.4%
30
18
43
49
87.8%
87.8%
31
19
23
49
46.9%
46.9%
32
20
33
49
67.3%
67.3%
33
12
15
80.0%
34
13
15
86.7%
35
9
15
60.0%
36
15
15
100.0%
37
13
15
86.7%
38
8
15
53.3%
39
11
15
73.3%
40
9
15
60.0%
TOTALS:
889
1320
67.3%
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69.1%