1.
EATING - Mr. D is able to swallow thin liquids and any consistency of food without problems. He requires dentures in order to eat and feeds himself independently.
A. 
B. 
6 or Modified Independent
C. 
D. 
2.
GROOMING - Mr. D sits in a wheelchair at the sink and his girlfriend brings him his supplies. He is able to wash, rinse and dry his face and hands. He brushes his teeth and shaves independently. He is able to comb his hair without help.
A. 
6 or Modified Independent
B. 
C. 
D. 
3.
BATHING - Bathing on a shower bench with arm rests and a back rest, Mr. D is able to wash, rinse and dry his arms, chest, abdomen and upper legs. He is able to lean over to bathe his lower legs and feet without assistance. However, a helper bathes his buttocks and perineal area.
A. 
B. 
C. 
D. 
4.
DRESSING UPPER BODY - After a helper sets out his shirt, Mr. D is able to put his t-shirt and sweatshirt on. He is independent in undressing and throws his own laundry in a basket that his girlfriend will pick up in a few days.
A. 
6 or Modified Independent
B. 
C. 
D. 
5.
DRESSING LOWER BODY - While seated in bed, Mr. D has difficulty threading his legs into his sweatpants, and he requires assistance with this task. Otherwise, he can pull up his pants independently. He is able to put his socks and shoes on, with extra time, and take them off independently. He removes his sweatpants independently and does not wear underwear.
A. 
B. 
C. 
D. 
6 or Modified Independent
6.
TOILETING - With contact guard assistance, Mr. D is able to pull down his sweatpants without assistance and sit on the toilet. He needs steadying assistance to lean forward so he can clean himself with toilet paper. He needs help pulling up his sweatpants. (Remember, it's a math problem)
A. 
B. 
C. 
D. 
7.
BLADDER - On admission, the nurse removed Mr. D's indwelling catheter, and started an intermittent catheter schedule every 4 hours. Mr. D is not voiding at all in between catheterizations. What is the level of assistance?
A. 
B. 
C. 
D. 
8.
BLADDER - The following day, Mr. D is using a urinal but he has an bladder accident on evenings requiring a helper to change the linens and clothing. What is the level of assistance?
A. 
B. 
C. 
D. 
9.
BOWEL - The nurses are working to manage the patients bowels with a suppository every other morning. On one occasion, after the suppository was inserted by the nurse, Mr.D had a bowel movement on the toilet. The patient performed 25-49% of the task of inserting the suppository.
A. 
B. 
C. 
D. 
10.
BED/CHAIR/WHEELCHAIR TRANSFER - After raising his bed height, Mr. D. can transfer from bed to the wheelchair, once a helper has locked the wheelchair brakes. He has more difficulty transferring from the wheelchair back to the bed. Mr. D. performs a little less than half the effort involved in the transfer.
A. 
B. 
C. 
D. 
11.
TOILET TRANSFER - Mr. D. is able to transfer from the wheelchair to the toilet with contact guard assist, but needs a little lifting when returning to the wheelchair.
A. 
B. 
C. 
D. 
12.
LOCOMOTION - Mr. D can propel himself in a manual wheelchair for over 175 feet. He requires intermittent verbal cues when negotiating corners or estimating the space that his wheelchair could fit in, for example, when trying to get on the elevator.
A. 
B. 
C. 
D. 
Modified Independent or 6
13.
STAIRS - Mr. D has not attempted stairs, but is independent in using an elevator to get to his therapy sessions, located 2 floors down from his hospital room.
A. 
B. 
C. 
Activity did not occur or 0
D. 
Modified Independent or 6
14.
Comprehension - The staff often need to gesture to Mr. D, during his therapy sessions. His sister is present during therapy sessions to help him participate. Mr. D is able to understand basic commands over half the time, with consistent gesturing and prompting by the staff and his sister.
A. 
B. 
C. 
D. 
15.
Expression - Staff members are able to understand what Mr. D is trying to express. He asks questions and talks about his daily care, but does not discuss more complex issues. He requires prompting less than 10% of the time to be understood.
A. 
B. 
C. 
D. 
Complete Independence or 7
16.
Social Interaction - Mr. D participates in activities or therapy sessions only if his sister is there to assist. She assists less than 10% of the time. When he participates, he is appropriate.
A. 
B. 
C. 
D. 
17.
Problem Solving - Mr. D's room is close to the nurse's station because he periodically tries to climb over the side rails to get out of bed. He does not require a 1:1. Mr. D shows appropriate problem solving 55% of the time.
A. 
B. 
C. 
D. 
18.
Memory - Mr. D requires constant cuing to maintain hip precautions. He needs to be reminded continually not to get out of bed on his own. A few minutes after reviewing hip precautions, Mr. D is seen bending over in the wheelchair trying to pick up a piece of paper that had fallen onto the floor. He does not effectively remember these precautions nor does he recognize staff he encouters each day.
A. 
B. 
C. 
D.