Intent:
To record what the person did for him/her self and how others assisted in the performance of the self-care activities of daily living during the last 3 days.
Definition:
ADL self-performance — measures based on all episodes of the activity over the last 3 days. The following are the performance-based items.
Bathing — How takes a full-body bath/shower. Includes how transfers in and out of tub or shower AND how each part of body is bathed: arms, up-per and lower legs, chest, abdomen and perineal area – EXCLUDE WASHING OF BACK AND HAIR.
Personal hygiene — How manages personal hygiene, including combing hair, brushing teeth, shaving, applying make-up, washing and drying face and hands – EXCLUDE BATHS AND SHOWERS.
Dressing upper body — How dresses and undresses (street clothes, underwear) above the waist, including prostheses, orthotics, fasteners, pull-overs, etc.
Dressing lower body — How dresses and undresses (street clothes, underwear) from the waist down including prostheses, orthotics, belts, pants, skirt, shoes, fasteners, etc.
Walking — How walks between locations on same floor indoors.
Locomotion — How moves between locations on same floor (walking or wheeling). If in wheelchair, self-sufficiency once in chair.
Transfer toilet — How moves on and off toilet or commode.
Toilet use — How uses the toilet room (or commode, bedpan, urinal), cleanses self after toilet use or incontinent episode(s), changes bed pad, manages ostomy or catheter, adjusts clothes - EXCLUDE TRANSFER ON AND OFF TOILET.
Bed mobility — How moves to and from lying position, turns from side to side, and positions body while in bed.
Eating — How eats and drinks (regardless of skill). Includes intake of nourishment by other means (e.g., tube feeding, total parenteral nutrition).
Set-up help — Assistance characterized by the provision of articles, devices, or preparation necessary for the person’s self-performance of an activity. This includes giving or holding out an item the person takes from the other person, but the other person leaves the person alone to complete the activity. If some-one remains nearby to watch over the person, the person is receiving over-sight, thus the code should be “2” Supervision.
Examples of set-up help:
Personal hygiene — providing a washbasin or grooming articles.
Walking — handing the person a walker or cane.
Toilet use — handing the person a bedpan or placing within reach the articles necessary for changing an ostomy appliance.
Eating — cutting meat or opening containers at meals, carrying a tray to a table, giving one food category at a time.
Weight bearing — People require varying degrees of physical assistance to complete ADL tasks. A key concept in grading the degree of assistance is the degree of weight-bearing support provided. When relating to non-upright positions, weight bearing refers to weight support (i.e., a helper may hold the full weight of an arm while assisting with putting on a shirt). When referring to standing or walking, weight-bearing support refers to taking the person’s weight by holding him/her under the armpit and/or allowing the person to help support their weight by leaning on the helper’s arm. Guiding movements with minimal physical contact and contact guarding with intermittent physical assistance are considered non-weight bearing.
Activity did not Occur vs Total Dependence — Do not confuse a person’s total dependence in an ADL activity (code “6” Total Dependence) with non-occurrence of the activity itself (code ‘8’). For example, even a person who receives tube feedings and no food or fluids by mouth is engaged in eating (receiving nourishment) and must be evaluated under the eating category for his/her level of assistance in the process. A person who is highly involved in giving him/herself a tube feeding is not totally dependent and should not be coded as “6”, but as a lower code, dependent on the nature of the help received from others.
Process:
To describe functioning, the assessor should first get a sense of the episodes in each ADL area over the last 3 days. Determine what the person does for him/herself and the nature of assistance provided (if any).
When ADL self-performance in an area varies over the last 3 days, identify the three most-dependent episodes — i.e., the episodes when the person received the greatest care or assistance from others. The summarization that is done to develop the ADL scores (as described below) focus on the most de-pendent episodes, providing a picture of the person’s need for input by others in managing this ADL.
In order to accomplish this, gather information as follows:
Gather information from multiple sources (e.g., discussion with the person, family, staff and others).
Ask questions pertaining to all aspects of the ADL activity definitions. For example, when discussing personal hygiene, inquire how the person manages washing in the morning, combing hair, brushing teeth, and shaving. A person can be independent in one aspect of personal hygiene yet re-quire extensive assistance in another aspect.
Observe how the person is performing the physical tasks.
Talk with the person to ascertain what he/she does for him/herself in each ADL activity, as well as the type and level of assistance provided by others.
If possible, talk with immediate caregivers or family members
Finally, weigh all responses to come up with a consistent picture of the person’s ADL performance for each episode assessed in each area.
The following are the ADL Self-Performance scoring rules:
(1) If all episodes in the 3-last days are performed at the same support level, score ADL at that level.
Note: For 0=Independent, 6=Total Dependence, and 8=Activity Did Not Occur, this is the only way a person can be scored into these levels – all performance episodes must be at these levels.
Note: This rule also applies even when where there was only one performance episode during the 3-day period (e.g., if the person only moved once during the three days between locations on same floor but was bed-bound for the remainder of the time, then score Locomotion based on the single episode when they moved).
(2) If any episodes at level 6, and other episodes were less dependent, score ADL as a 5.
(3) Otherwise, focus on the three most dependent episodes [or all episodes if performed fewer that 3 times].
If most dependent of these episodes is 1, score ADL as 1. If not, score ADL as least dependent of those episodes in range 2-5.
Scoring Levels into which person is thus placed
0. Independent — No physical assistance, setup, or supervision in any episode
1. Independent, setup help only — Article or device provided or placed within reach, no physical assistance or supervision in any episode
2. Supervision-Oversight/cuing
3. Limited assistance — Guided maneuvering of limbs, physical guidance without taking weight
4. Extensive assistance — Weight-bearing support (including lifting limbs) by 1 helper where person still performs 50% or more of subtasks
5. Maximal assistance — Weight-bearing support (including lifting limbs) by 2+ helpers -OR- Weight-bearing support for more than 50% of sub-tasks
6. Total dependence — Full performance by others during all episodes
8. Activity did not occur during entire period
The following chart provides general guidelines for recording accurate ADL Self-Performance.
Guidelines for Assessing ADL Self-Performance
The coding scale for ADLs records the person's actual level of involvement in self-care and the type and amount of support actually received during the last three days.
Do not base your assessment on the person's capacity for involvement in self-care — i.e., what you believe the person could do for him/herself.
Do not record the type and level of assistance you think the person “should” be receiving (e.g., based on a written plan of care or expectations the family may have). The type and level of assistance actually provided might be quite different from what is indicated in a care plan. Record what is actually happening.
Engage family (or formal home care staff when possible who have cared for the person over the last three days) in discussions regarding the person's ADL functions. Remind these persons that the focus is on the last three days only. To clarify your own under-standing and observations about each ADL activity (bed mobility, walking, transfer, etc.), ask probing questions, beginning with the general and proceeding to the more specific.
Example
Here is a possible conversation between the assessor and family member regarding rising from a chair for a person who is severely impaired.
Assessor: “Tell me how Mrs. L gets up from the chair. Once she is on the chair, how does she move from a sitting to a standing position?”
Family member: “She can move about by herself, but I help her to grab the side rails as she gets up.”
Assessor: “Do you give her verbal instructions or does this involve physical help?”
Family member: “Most of the time I just remind her to grab the side rails of the chair when she gets up. If she doesn't, she might fall. But once I tell her how to do things, she can do it herself.”
Assessor: “So, how do you help as she actually rises from the chair?”
Family member: “She can help herself by grabbing onto the rail. I tell her what to do. There are times each day when I hold her arm to steady her in getting up.”
Assessor: “How many days during the three days did you give this type of help?
Family member: “Every day.”
For Transfer, Mrs. L would receive an ADL Self-Performance Code of “4” (Extensive Assistance).