SCIMSCORE
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Personal Data
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Tue, 07/27/2010 - 13:44 — tribase
Caregiver Data
Caregiver Profession (Examples: Physician / Nurse / PT / OT):
Caregiver's Name:
Caregiver's Hospital/Institution:
*
country:
*
Fax:
E-mail:
*
Patient Data
Patient Code (given by the caregiver for identification):
*
Patient Age:
*
Patient Gender :
*
Male
Female
Spinal cord lesion neurological level (C1-S5):
*
American Spinal Injury Association Impairment Scale (AIS) grade:
*
American Spinal Injury Association motor score (AMS):
*
Spinal cord lesion etiology:
SCIM Scores
Self-Care
1: Feeding (cutting, opening containers, pouring, bringing food to mouth, holding cup with fluid):
*
0: Needs parenteral, gastrostomy, or fully assisted oral feeding
1: Needs partial assistance for eating and/or drinking, or for wearing adaptive devices
2: Eats independently; needs adaptive devices or assistance only for cutting food and/or pouring and/or opening containers
3: Eats and drinks independently; does not require assistance or adaptive devices
2: Bathing (soaping, washing, drying body and head, manipulating water tap)
A: upper body:
*
0: Requires total assistance
1: Requires partial assistance
2: Washes independently with adaptive devices or in a specific setting (e.g., bars, chair)
3: Washes independently; does not require adaptive devices or specific setting (not customary for healthy people) (adss)
B: lower body:
*
0: Requires total assistance
1: Requires partial assistance
2: Washes independently with adaptive devices or in a specific setting (adss)
3: Washes independently; does not require adaptive devices (adss) or specific setting
3: Dressing (clothes, shoes, permanent orthoses: dressing, wearing, undressing).
A: upper body:
*
0: Requires total assistance
1: Requires partial assistance with clothes without buttons, zippers or laces (cwobzl)
2: Independent with cwobzl; requires adaptive devices and/or specific settings (adss)
3: Independent with cwobzl; does not require adss; needs assistance or adss only for bzl
4: Dresses (any cloth) independently; does not require adaptive devices or specific setting
B: lower body:
*
0: Requires total assistance
1: Requires partial assistance with clothes without buttons, zippers or laces (cwobzl)
2: Independent with cwobzl; requires adaptive devices and/or specific settings (adss)
3: Independent with cwobzl without adss; needs assistance or adss only for bzl
4: Dresses (any cloth) independently; does not require adaptive devices or specific setting
4: Grooming (washing hands and face, brushing teeth, combing hair, shaving, applying makeup):
*
0: Requires total assistance
1: Requires partial assistance
2: Grooms independently with adaptive devices
3: Grooms independently without adaptive devices
Respiration and Sphincter Management
5: Respiration:
*
0: Requires tracheal tube (TT) and permanent or intermittent assisted ventilation (IAV)
2: Breathes independently with TT; requires oxygen, much assistance in coughing or TT management
4: Breathes independently with TT; requires little assistance in coughing or TT managemen
6: Breathes independently without TT; requires oxygen, much assistance in coughing, a mask (e.g., peep) or IAV (bipap)
8: Breathes independently without TT; requires little assistance or stimulation for coughing
10: Breathes independently without assistance or device
6: Sphincter Management - Bladder:
*
0: Indwelling catheter
3: Residual urine volume (RUV) > 100cc; no regular catheterization or assisted intermittent catheterization
6: RUV < 100cc or intermittent self-catheterization; needs assistance for applying drainage instrument
9: Intermittent self-catheterization; uses external drainage instrument; does not need assistance for applying
11: Intermittent self-catheterization; continent between catheterizations; does not use external drainage instrument
13: RUV <100cc; needs only external urine drainage; no assistance is required for drainage
15: RUV <100cc; continent; does not use external drainage instrument
7: Sphincter Management - Bowel:
*
0: Irregular timing or very low frequency (less than once in 3 days) of bowel movements
5: Regular timing, but requires assistance (e.g., for applying suppository); rare accidents (less than twice a month)
8: Regular bowel movements, without assistance; rare accidents (less than twice a month)
10: Regular bowel movements, without assistance; no accidents
8: Use of Toilet (perineal hygiene, adjustment of clothes before/after, use of napkins or diapers):
*
0: Requires total assistance
1: Requires partial assistance; does not clean self
2: Requires partial assistance; cleans self independently
4: Uses toilet independently in all tasks but needs adaptive devices or special setting (e.g., bars)
5: Uses toilet independently; does not require adaptive devices or special setting
Mobility (room and toilet)
9: Mobility in Bed and Action to Prevent Pressure Sores:
*
0: Needs assistance in all activities: turning upper body in bed, turning lower body in bed,sitting up in bed, doing push-ups in wheelchair, with or without adaptive devices, but not with electric aids
2: Performs one of the activities without assistance
4: Performs two or three of the activities without assistance
6: Performs all the bed mobility and pressure release activities independently
10: Transfers: bed-wheelchair (locking wheelchair, lifting footrests, removing and adjusting arm rests, transferring, lifting feet):
*
0: Requires total assistance
1: Needs partial assistance and/or supervision, and/or adaptive devices (e.g., sliding board)
2: Independent (or does not require wheelchair)
11: Transfers: wheelchair-toilet-tub (if uses toilet wheelchair: transfers to and from; if uses regular wheelchair: locking wheelchair, lifting footrests, removing and adjusting armrests, transferring, lifting feet):
*
0: Requires total assistance
1: Needs partial assistance and/or supervision, and/or adaptive devices (e.g., grab-bars)
2: Independent (or does not require wheelchair)
Mobility (indoors and outdoors, on even surface)
12: Mobility Indoors:
*
0: Requires total assistance
1: Needs electric wheelchair or partial assistance to operate manual wheelchair
2: Moves independently in manual wheelchair
3: Requires supervision while walking (with or without devices)
4: Walks with a walking frame or crutches (swing)
5: Walks with crutches or two canes (reciprocal walking)
6: Walks with one cane
7: Needs leg orthosis only
8: Walks without walking aids
13: Mobility for Moderate Distances (10-100 meters):
*
0: Requires total assistance
1: Needs electric wheelchair or partial assistance to operate manual wheelchair
2: Moves independently in manual wheelchair
3: Requires supervision while walking (with or without devices)
4: Walks with a walking frame or crutches (swing)
5: Walks with crutches or two canes (reciprocal walking)
6: Walks with one cane
7: Needs leg orthosis only
8: Walks without walking aids
14:Mobility Outdoors (more than 100 meters):
*
0: Requires total assistance
1: Needs electric wheelchair or partial assistance to operate manual wheelchair
2: Moves independently in manual wheelchair
3: Requires supervision while walking (with or without devices)
4: Walks with a walking frame or crutches (swing)
5: Walks with crutches or two canes (reciprocal waking)
6: Walks with one cane
7: Needs leg orthosis only
8: Walks without walking aids
15: Stair Management:
*
0: Unable to ascend or descend stairs
1: Ascends and descends at least 3 steps with support or supervision of another person
2: Ascends and descends at least 3 steps with support of handrail and/or crutch or cane
3: Ascends and descends at least 3 steps without any support or supervision
16: Transfers: wheelchair-car (approaching car, locking wheelchair, removing arm- and footrests, transferring to and from car, bring wheelchair into and out of car):
*
0: Requires total assistance
1: Needs partial assistance and/or supervision and/or adaptive devices
2: Transfers independent; does not require adaptive devices (or does not require wheelchair)
17: Transfers: ground-wheelchair:
*
0: Requires assistance
1: Transfers independent with or without adaptive devices (or does not require wheelchair)
SCIM Calculation
grade:
median:
totalSum:
SCIARMI-Sum:
SC
SC-SCI-ARMI:
SC-SCI-Sum:
RSM
RSM-SCI-ARMI:
RSM-SCI-Sum:
MOB
MOB-SCI-ARMI:
MOB-SCI-Sum: