270 Northpointe Parkway, Suite 300, Amherst, New York 14228

tel: 716-817-7800 • fax: 716-568-0037

Uniform Data System

for Medical Rehabilitation The Functional Assessment Specialists

Helpful Hints for Rating the

AlphaFIM® Instrument

© 2009, 2012 Uniform Data System for Medical Rehabilitation. AlphaFIM, FIM, and the UDSMR logo are trademarks of
Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc.
 Helpful Hints for Rating the AlphaFIM® Instrument
Uniform Data System for Medical Rehabilitation, January 10, 2012

The
Contents
Functional General Hints ................................................................................................................... 1
Assessment Locomotion: Walk ........................................................................................................... 3
Specialists Transfers: Bed, Chair ....................................................................................................... 4
Eating ............................................................................................................................... 5
Grooming ......................................................................................................................... 6
Bowel Management ......................................................................................................... 7
Transfers: Toilet............................................................................................................... 8
Expression........................................................................................................................ 9
Memory.......................................................................................................................... 10

Uniform
Data
System
for Medical
Rehabilitation

Telephone
716.817.7800

Fax
716.568.0037

E-mail
info@udsmr.org

Web site
www.udsmr.org

Suite 300
270 Northpointe Parkway
Amherst, NY 14228
General Hints
The AlphaFIM® instrument is an abbreviated version of the FIM® instrument. It was designed to
assess disability and functional status in the acute care setting. UDSMR recommends that an
assessment be performed within 72 hours of admission to the acute hospital, but multiple
assessments may be performed during the hospital stay and upon discharge.
• The AlphaFIM® items—four motor items and two cognitive items—were selected from the
FIM® instrument for their practicality. The six items depend on the patient’s observed
walking distance:
Patient A (walks less than 150 feet): Patient B (walks 150 feet or more):
1. Eating 1. Transfers: Bed, Chair
2. Grooming 2. Locomotion: Walk
3. Bowel Management 3. Bowel Management
4. Transfers: Toilet 4. Transfers: Toilet
5. Expression 5. Expression
6. Memory 6. Memory
• Each of the AlphaFIM® items has a maximum rating of seven (7), which indicates complete
independence. With the exception of Locomotion: Walk, a rating of one (1) indicates total
assistance. If the patient does not walk at least 150 feet, Locomotion: Walk will not be
assessed. If the patient does walk at least 150 feet, the minimum rating of three (3) indicates
that the patient requires moderate assistance from a helper to achieve that distance.
• Motor components of the AlphaFIM® instrument measure the patient’s function in the areas
of self-care, sphincter control, transfers, and walking.
• If differences in function occur in different environments or at different times of the day,
record the lowest (most dependent) rating. If a specific activity is not observed, team
members on the acute floor may need to help you determine the most dependent rating.
• Communication and social cognition components of the AlphaFIM® instrument measure the
patient’s function in the areas of expression and memory.
• Consider the entire day (24 hours), and determine the percentage of the day during which
the patient requires prompting.
• Do not record the lowest (most dependent) individual rating for Expression and Memory;
instead, determine the patient’s need for prompting or cueing from a helper over the
24-hour time frame.
• Use only whole numbers when rating AlphaFIM® items.
• When performing an assessment, record the AlphaFIM® rating that best describes the
patient’s level of function for every AlphaFIM® item. Do not leave any AlphaFIM® item
blank.
• If an AlphaFIM® activity does not occur, rate the item level 1, Total Assistance. If you
receive reliable information from an acute care staff member for an unobserved activity, you
may use that rating (e.g., the Eating rating for that morning’s breakfast meal).

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• Patients who receive assistance from a helper may never be rated level 6 or level 7. For
example, a patient who needs frequent reminders to perform a motor activity would be rated
level 5 because of cueing/prompting required by a helper. The amount of cueing and
prompting from a helper will determine the appropriate rating for Expression and Memory,
from level 5 to level 1.
• Level 5 involves setup or supervision, cueing, or coaxing. It does not involve touching unless
such touching is part of setup (e.g., applying a prosthesis or orthosis).
• For Expression and Memory, determine whether the patient’s performance fluctuates in
complex/abstract areas. If the patient is fluctuating, rate the patient level 5 or lower.
• If the patient performs all basic daily reasoning, rate the patient level 5.
• If the patient functions well with basic daily information but needs cueing or prompting
from a helper for complex/abstract information (less than 10 percent of the time), rate the
patient level 5.
• If a patient requires steadying, touching, or contact guard assistance while performing motor
activities, rate the patient level 4.
• If a patient requires lifting assistance, rate the patient level 3 or lower depending on the
amount of lifting assistance required:
• If a patient needs help with lifting one limb only—such as lifting leg onto the bed while
transferring—rate the patient level 4.
• If a patient needs help with lifting two limbs—such as lifting both legs into a bed—rate
the patient level 3.
• At level 3, the patient approaches the chair or bed with no more than contact assistance,
but the patient requires lifting assistance to either stand up or sit down.
• At level 2, the patient approaches the chair or bed with no more than contact assistance,
but the patient requires lifting assistance to stand up and sit down.
• At level 1, the patient requires more than contact assistance to approach the chair or bed,
sit down, and stand up.
• If a patient performs just more than half of a task, rate the patient level 3 for that task. For
example, if a helper asks the patient to repeat information “just less than half the time,”
indicating that the patient performs without repetition just over half the time, rate the patient
level 3 for Expression.
• If a patient performs less than half of a task (i.e., the patient puts forth less than 50 percent of
the effort), rate the patient level 2.
• If a patient is completely dependent for care, performs less than 25 percent of an activity, or
requires two or more helpers, rate the patient level 1.

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Locomotion: Walk
Locomotion: Walk includes walking on a level surface once the patient is in a standing position.
The patient performs the activity safely.
Rate this item based on the patient’s performance without rest periods or breaks.
If a patient ambulates 150 feet without a device and without a helper, and does so in a safe and
timely manner, rate the patient level 7, Complete Independence.
If a patient ambulates 150 feet or more, the patient’s rating can range from level 3 to level 7. If
the patient uses an assistive device (walker, cane, or crutches), the patient’s rating can range
from level 3 to level 6.
If a patient ambulates 150 feet or more and uses a device for mobility, such as a walker, cane,
adapted shoe, AFO, or prosthesis, rate the patient level 6, Modified Independence, but only if the
patient sets up or applies the device without assistance from a helper. If the patient requires more
than a reasonable amount of time to walk this distance, or if there is a safety concern for which
the patient takes responsibility, rate the patient level 6, Modified Independence.
If a patient ambulates 150 feet but requires verbal cues or supervision, rate the patient level 5,
Supervision/Setup.
If the patient ambulates 150 feet but requires minimal assistance (to occasionally move the
walker, for example, or to occasionally move the patient’s foot forward) and performs 75 percent
or more of the walking effort, rate the patient level 4, Minimal Assistance.
If the patient ambulates 150 feet but requires moderate assistance, and the patient performs 50
percent to 74 percent of the walking effort, rate the patient level 3, Moderate Assistance.

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Transfers: Bed, Chair
Transfers: Bed, Chair includes all aspects of transferring from a bed to a chair and back or
coming to a standing position if walking is the typical mode of locomotion. The patient performs
the activity safely starting and ending in a supine position. Transfers: Bed, Chair includes bed
mobility.
The patient safely approaches, sits down on, and gets up to a standing position from a regular
chair. The patient also safely transfers from bed to chair.
During the bed-to-chair transfer, the patient begins in a supine position and ends in a sitting
position.
During the chair-to-bed transfer, the patient begins in a sitting position and ends in a supine
position.
Bedrails and walkers are considered assistive devices for this item if the patient requires them to
complete transfers.
At level 6, the patient requires that the head of the bed be raised to transfer from a supine
position to a sitting position, but the patient does not require a helper. The patient requires extra
time to transfer, or there is a concern for the patient’s safety for which the patient takes
responsibility.
At level 5, the patient requires setup, cueing, coaxing, or supervision.
At level 4, the patient requires touching, steadying, or contact guard assistance or requires a
helper to lift only one leg onto or off the bed.
At level 4, the patient needs help with lifting one limb only—such as lifting one leg onto a bed
while transferring.
At level 3, the patient needs help with lifting two limbs—such as lifting both legs into a bed.
At level 3, the patient approaches a chair or bed with no more than contact assistance but
requires lifting assistance to either stand up or sit down.
At level 2, the patient approaches a chair or bed with no more than contact assistance but
requires lifting assistance to stand up and sit down.
At level 1, the patient requires more than contact assistance to approach a chair or bed, sit down,
and stand up.
At level 1, a helper performs all tasks, the patient utilizes a mechanical lift, or more than one
helper is required.
If transfers into and out of bed require different levels of assistance, record the lower AlphaFIM®
rating (i.e., the rating that reflects the higher burden of care).
This item should be rated on the patient’s overall functional performance for this item. Do not
try to assign levels for each component (bed mobility, supine to sit, etc.).

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Eating
Eating includes the ability to use suitable utensils to bring food to the mouth, as well as the
ability to chew and swallow the food once the meal is presented in the customary manner on a
table or tray. The patient performs this activity safely.
Assistance may be required with any of the following elements:
• Picking up a utensil
• Scooping food
• Bringing hand to mouth
• Chewing and swallowing food
• Bringing a cup or glass to the mouth, where the liquid is swallowed
Assistive devices include universal cuffs, adaptive utensils, and dentures (if the patient must
have them to eat). Setup includes cutting food, opening containers, and applying an orthosis.
If the patient eats by mouth without assistance (level 7) but also requires tube feedings (i.e.,
nasogastric or gastrostomy tube), the AlphaFIM® rating may range from level 6, Modified
Independence, to level 1, Total Assistance, depending on the patient’s level of participation:
• If the patient performs the tube feedings independently, including setup, rate the patient level
6, Modified Independence.
• If the patient requires setup assistance, cueing, or both to complete the tube feeding, rate the
patient level 5, Supervision/Setup.
• If a helper administers the feeding entirely, rate the patient level 1, Total Assistance.
The following helpful hints should help you complete the Eating rating:
• If the patient receives IV fluids for hydration or nutrition and a helper administers the IV,
rate the patient level 1, Total Assistance.
• If the patient receives nutrition or hydration through a gastrostomy tube administered by a
helper, rate the patient level 1, Total Assistance.
• If the patient has a gastrostomy tube but is not relying upon it for hydration or nutrition, and
the helper flushes it to maintain patency only, this represents medical management, and it
would not be rated for Eating.
• If the patient uses dentures to eat, rate the patient level 6, Modified Independence.
• If a helper inserts the dentures for the patient, rate the patient level 5, Supervision/Setup.
If a staff member feeds the patient an entire meal, but the patient chews and swallows the food
and brings a drink to the mouth and swallows, rate the patient level 2, Maximal Assistance. (The
patient performs 25 percent of the overall task.)

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Grooming
Grooming includes oral care, hair grooming (brushing or combing hair), washing the hands
(including rinsing and drying), washing the face (including rinsing and drying), and either
shaving the face or applying make-up. If the patient neither shaves nor applies make-up, then this
item includes only the first four tasks. The patient performs the activity safely. This item
includes obtaining articles necessary for grooming.
Grooming does not include such tasks as shampooing hair, caring for nails, flossing teeth, or
applying deodorant. Setup includes gathering articles necessary for grooming.
Do not include help to get to the sink or to get into and out of the bathroom.
If a patient uses equipment but does not receive any assistance from a helper, rate the patient
level 6, Modified Independence.
If a patient requires only prior preparation (e.g., placing soap, opening a denture packet, or
placing grooming equipment within reach) or supervision (including cueing, coaxing,
instructions, or encouragement), rate the patient level 5, Supervision/Setup.
If a patient requires physical assistance with grooming, determine the percent of grooming
effort by assessing the patient’s need for assistance with the following grooming tasks:
1. Oral care (brushing teeth or cleaning dentures)
2. Grooming hair (combing or brushing hair)
3. Washing, rinsing, and drying hands
4. Washing, rinsing, and drying the face
5. Shaving the face or applying make-up
Each of the tasks listed above represents 20 percent of grooming tasks if all five items are
addressed. If a patient requires more than supervision or setup assistance (level 5), a “percent of
grooming tasks” may be calculated, based on how many grooming tasks the patient completes.
Note that shaving the face and applying make-up should be disregarded for those who do not
perform these tasks. If neither task is applicable, the Grooming rating will be based on the other
four activities (oral care, hair grooming, washing the hands, and washing the face). In this case,
each grooming task is equivalent to about 25 percent of grooming tasks.
If a patient sits in a chair and performs grooming tasks at the sink, do not consider the chair an
assistive device for Grooming.

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Bowel Management
Bowel Management includes complete and intentional control of bowel movements and use of
any necessary equipment or agents for bowel control. Assess the need for assistance associated
with bowel management (accidents or incontinent episodes).
Note: The Bowel Management rating does not include getting to and from the bathroom or
transferring onto and off a toilet, elevated toilet seat, or commode.
The functional goal of bowel management is to open the anal sphincter only when needed and to
keep it closed the rest of the time. This may require a combination of devices, medications
(agents), and assistance for some patients.
Definition of “bowel accident”: A bowel accident refers to the act of soiling linen or clothing
with stool. It includes bedpan spills.
The assessment time frame for Bowel Management is 24 hours. Documentation should include
the following:
• The level of assistance required over the 24-hour period to prevent an accident or an
incontinent episode
• The level of assistance needed to clean up after an accident or an incontinent episode
If the patient does not have a bowel movement during the entire 24-hour assessment time frame,
and the patient does not use an assistive device or medication for bowel control, rate the patient
level 7, Complete Independence.
Medications used for bowel management are agents; if a patient uses such medication, the
highest possible rating for this item is level 6, Modified Independence.
Natural agents (e.g., prune juice, herbal tea, high-fiber diet) are not considered assistive devices
for bowel management.
If the patient is on a bowel program and using suppositories, the AlphaFIM® rating may range
from level 6, Modified Independence, to level 1, Total Assistance.
At level 6, the patient manages his own bowel program. This includes inserting his own
suppository and performing his own preparation and cleanup.
At level 5, a helper provides assistance with either prior preparation or cleanup or provides
cueing, coaxing, or instructions for use of an assistive device.
At level 4, a helper inserts a suppository but does not provide any digital stimulation. The patient
transfers to the toilet/commode, eliminates, and provides his own cleanup.
At level 1, the patient does not participate in his bowel program—a helper provides all the
assistance. If the patient has an accident or an incontinent episode, a helper is required to change
linen or clothing. Rate the patient level 1, Total Assistance, if a helper must change the diaper or
absorbent pad or if a helper is required to perform digital stimulation.

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Transfers: Toilet
Transfers: Toilet includes safely getting on and off a standard toilet.
The AlphaFIM® rating for this item includes the patient’s approach to the toilet once the patient
is in the bathroom. For example, if a patient walks and requires touching assistance to step to the
toilet once in the bathroom, but the patient can then sit and stand with supervision, rate the
patient level 4, Minimal Assistance.
At level 6, the patient requires an adaptive/assistive device, such as a sliding board, grab bar,
raised toilet seat, or bedside commode. The patient may need extra time to transfer, or there is a
safety concern for which the patient takes responsibility.
At level 5, the patient requires setup, cueing, coaxing, or supervision.
At level 4, the patient requires touching, steadying, or contact guard assistance.
At level 3, the patient approaches the toilet with no more than contact assistance but requires
lifting assistance to either stand up or sit down.
At level 2, the patient approaches the toilet with no more than contact assistance but requires
lifting assistance to stand up and sit down.
At level 1, the patient requires more than contact assistance to approach the toilet, sit down, and
stand up.
At level 1, a helper performs all tasks, the patient utilizes a mechanical lift, or more than one
helper is required.

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Expression
Expression includes clear vocal or nonvocal expression of language. This item includes either
intelligible speech or clear expression of language using writing or a communication device.
Determine whether the patient uses primarily vocal or nonvocal means of expression. The
AlphaFIM® rating should reflect the more usual mode of expression, even if the patient uses both
modes.
Definitions:
• Basic needs and ideas: Necessary daily activities, such as hunger, thirst, elimination, hygiene,
sleep, fear, pain, and other psychological needs.
• Complex or abstract ideas: Current events, religion, relationship with others, etc.
If a patient expresses complex and abstract information clearly and intelligibly, rate the patient
level 7, Complete Independence.
If a patient expresses complex and abstract information with mild difficulty, but self-corrects,
rate the patient level 6, Modified Independence.
If a patient expresses complex and abstract information, but the patient uses an assistive
device (e.g., communication board, computer) to do so or requires extra time, rate the patient
level 6, Modified Independence. An interpreter is not considered an assistive device.
If a patient expresses complex or abstract information but requires prompting from a helper
less than 10 percent of the time to express a message or thought, rate the patient level 5, Standby
Prompting.
If a patient expresses only basic information, rate the patient level 5, Standby Prompting, or
lower.
If a patient expresses only single words or simple gestures, a helper will likely provide a great
deal of assistance to help the patient. Rate such a patient level 2, Maximal Prompting.
Rate this item based on the patient’s usual language. Note that this might not be English.
Input from all disciplines will assist in assigning an accurate rating over a 24-hour period.
Regular interactions with a patient throughout the 24 hours provide a good indication of the
burden of care required during regular situations. Although formal evaluations will assist in
identifying specific areas of need, they may not always equate to burden of care.

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Memory
Memory includes skills related to recognizing and remembering while performing daily activities.
It includes storing and retrieving information, particularly verbal and visual.
The functional evidence of memory includes recognizing people frequently encountered,
remembering daily routines, and executing requests without being reminded. A deficit in
memory impairs learning as well as performance of tasks.
Memory has three key components:
1. Recognizing people frequently encountered
2. Remembering daily routines
3. Executing requests without reminders
For this item, a memory book, logbook, or cue card is considered an assistive device. If a patient
uses such a device without cueing or additional reminders, rate the patient level 6. If a helper
must remind or cue the patient to use the device, rate the patient level 5.
For commands and tasks, follow these guidelines:
• At level 7, the patient recalls three of three tasks.
• At level 6, the patient recalls three of three tasks with mild difficulty or sets up and uses an
assistive device. The patient may need extra time to retrieve information but does not need
reminders.
• At level 5, the patient recalls three of three tasks but requires cues less than 10 percent of the
time.
• At level 4, the patient recalls two of three tasks. The patient recognizes and remembers 75 to
90 percent of the time.
• At level 3, the patient recalls two of two tasks. The patient recognizes and remembers 50 to
74 percent of the time.
• At level 2, the patient recalls one of two tasks. The patient recognizes and remembers 25 to
49 percent of the time.
• At level 1, the patient does not recall either of two tasks and requires constant cues. The
patient recognizes and remembers less than 25 percent of the time.
Input from all disciplines will assist in assigning an accurate rating over a 24-hour period.
Regular interactions with a patient throughout the 24 hours provide a good indication of the
burden of care required during regular situations. Although formal evaluations will assist in
identifying specific areas of need, they may not always equate to burden of care.

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