FSS-ICU Scoring Form

Functional Status Score for the Intensive Care Unit (Version 8.11.15)

FSS-ICU validation and publications here

General Guidelines for Scoring:

The FSS-ICU score should be used to grade a patient's physical performance only. The evaluator may assist with managing medical devices and/or equipment, as well as supervising patient monitoring systems. Such assistance from the evaluator should not be considered when grading the patient's physical performance.
Unless otherwise stated (i.e. for ambulation and wheelchair mobility where scoring allows for 2 evaluators), scoring of the FSS-ICU should be based on only one evaluator physically assisting or supervising the patient with each given task. Scoring of the FSS-ICU must be performed without the use of a patient lift device to assist the patient.
Scoring should be based on what is performed in the session where testing occurs, not what the evaluator has witnessed the patient complete in the past or anticipates that the patient should be able to perform.

Specific Instructions for Scoring:

For each task, the minimum and maximum score is 0 and 7, respectively. The "Total Score" is the sum of items 1 through 5, and has a minimum and maximum of 0 and 35, respectively.

If task(s) were not performed for any other reason other than weakness:

If ≤2 tasks were not performed for such reasons, use the average score from the remaining completed items to score the 1 or 2 missing tasks.
If >2 tasks were not performed for such reasons, only the completed tasks can be scored and a total FSS-ICU total score cannot be calculated.

1. Rolling

Does the patient need assistance to roll in the bed?

[Testing Note: Place the bed as flat as safely possible for the patient]

No:

Does the patient perform rolling by themselves without the use of a bed rail or other object to pull on? If yes, score 7.

Does the patient require a use of a rail or object to pull on in order to roll themselves in bed? If yes, score 6.

Yes:

Does the patient require cueing or coaxing in order to roll, but physically can perform rolling without assistance (the patient may use a bed rail or object to pull self if needed)? If yes, score 5.

Does the patient require minimal assistance to perform rolling (defined as the patient performing 75% or more of the amount of the work)? If yes, score 4.

Does the patient require moderate assistance to perform rolling (defined as the patient performing between 26%-74% of the amount of work)? If yes, score 3.

Does the patient require maximum assistance to perform rolling (defined as the patient performing 25% or less of the amount of work)? If yes, score 2.

Is the patient completely dependent or unable to assist with rolling (defined as rolling performed, but patient not being able to assist at all)? If yes, score 1.

Is the patient unable to attempt or complete the task of rolling due to weakness? If yes, score 0.

If task(s) were not performed for any other reason other than weakness (e.g., patient declines, or patient's medical equipment prevents performance of the task), then do not score.

2. Supine to Sit Transfers

Does the patient require assistance to come to sitting from supine position?

[Testing Note: Place the bed as flat as safely possible for the patient]

No:

Does the patient come to sitting from a lying down position by themselves without the use of a bed rail or other object to pull on for support? If yes, score 7.

Does the patient come to sitting from a lying down position by themselves, but requires the use of a bed rail or other object to pull on for support? If yes, score 6.

Yes:

Does the patient require cueing or coaxing in order to come to sitting from a lying down position, but physically can perform without assistance (the patient may use a bed rail or object to assist themselves if needed)? If yes, score 5.

Does the patient require minimal assistance to come to sitting from a lying down position (defined as the patient performing 75% or more of the amount of the work?) If yes, score 4.

Does the patient require moderate assistance to come to sitting from a lying down position (defined as the patient performing between 26%-74% of the amount of the work?) If yes, score 3.

Does the patient require maximum assistance to come to sitting from a lying down position (defined as the patient performing 25% or less of the amount of the work?) If yes, score 2.

Is the patient completely dependent or unable to assist with transferring to sitting from a lying down position (defined as supine to sit transfer performed, but patient not being able to assist at all)? If yes, score 1.

Is the patient unable to attempt or complete the task of transferring from supine to sit due to weakness? If yes, score 0.

If task(s) were not performed for any other reason other than weakness (e.g., patient declines, or patient's medical equipment prevents performance of the task), then do not score.

3. Sit to Stand Transfers

Does the patient require assistance to stand up from a sitting position?

[Testing Note: Transfers can occur from any surface of a reasonable and customary height, including a bed, chair, etc.]

No:

Does the patient stand up or pull up from a seated position by themselves without the use of bed rail/ armrests or other object to push on or pull from? If yes, score 7.

Does the patient require the use of bed rail/armrests or other object to push on or pull from in order to stand up? If yes- score 6.

Yes:

Does the patient require cueing or coaxing in order to stand from a seated position, but physically can perform without assistance (the patient may use a bed rail/armrests or other objects to assist themselves if needed)? If yes, score 5.

Does the patient require minimal assistance to stand from a seated position (defined as the patient performing 75% or more of the amount of the work)? The patient may use armrests, if needed. If yes, score 4.

Does the patient require moderate assistance to stand from a seated position (defined as the patient performing between 26-74% of the amount of work)? If yes, score 3.

Does the patient require maximum assistance to stand from a seated position (defined as the patient performing 25% or less of the amount of work)? If yes, score 2.

Is the patient completely dependent or unable to assist with going from a seated to standing position (defined as sit to stand transfer performed, but patient not being able to assist at all)? If yes, score 1.

Is the patient unable to attempt or complete the task of transferring from sit to stand due to weakness? If yes, score 0.

If task(s) were not performed for any other reason other than weakness (e.g., patient declines, or patient's medical equipment prevents performance of the task), then do not score.

4. Sitting Edge of Bed

Does the patient require assistance in order to sit up at the side of the bed?

[Testing Note: There is no time requirement for this task]

No:

Does the patient sit at the side of the bed by themselves with hands free and not holding onto a bed rail or object for support? If yes, score 7.

Does the patient require their hand(s) or a bed rail to balance themselves while sitting up at the side of the bed by themselves? If yes, score 6.

Yes:

Does the patient require cueing or coaxing in order to sit at the side of the bed, but physically can perform without assistance (may use hand to balance themselves if needed)? If yes, score 5.

Does the patient require minimal assistance to sit at the side of the bed (defined the patient performing 75% or more of the amount of the work)? If yes, score 4.

Does the patient require moderate assistance to sit at the side of the bed (defined as the patient performing between 26-74% of the amount of work)? If yes, score 3.

Does the patient require maximum assistance to sit at the side of the bed (defined as the patient helping 25% or less of the amount of work)? If yes, score 2.

Is the patient completely dependent or unable to assist with sitting at the side of the bed (defined as sitting at the edge of the bed performed, but patient not being able to assist at all)? If yes, score 1.

Is the patient unable to attempt or complete the task of sitting at the side of the bed due to weakness? If yes, score 0.

If task(s) were not performed for any other reason other than weakness (e.g., patient declines, or patient's medical equipment prevents performance of the task), then do not score.

5. Walking

Does the patient need assistance to walk 150 feet (45 m)?

[Testing Note: Following the patient with a wheelchair or assisting with managing medical equipment while ambulating should not be considered as a second person assisting with the task]

No:

Can the patient walk 150 feet (45 m) without using an assistive device such as a cane, walker, crutches, or use of a brace or prosthesis? If yes, score 7.

Can the patient walk 150 feet (45 m) but requires the use of an assistive device such as a cane, walker, crutches, or use of a brace or prosthesis? If yes, score 6.

Yes:

Does the patient require only supervision or cueing in order to walk 150 feet (45 m) without physical help (the patient may use an assistive device as need)? If yes, score 5.

Can the patient walk a minimum of 150 feet (45 m) with minimum assistance of only one person (defined as the patient being able to perform 75% or more of the walking effort)? If yes, score 4.

Can the patient walk a minimum of 150 feet (45 m) with moderate assistance of only one person (defined as the patient being able to perform between 50 to 74% of the walking effort)? If yes, score 3.

Can the patient walk at least 50 feet (15 m) with the assistance of only one person? If yes, score 2.

Can the patient walk less than 50 feet (15 m) with the assistance of one person or requires the assistance of two people to physically assist with any ambulation distance? If yes, score 1.

Is the patient unable to attempt or complete the task of ambulation due to weakness? If yes, score 0.

If task(s) were not performed for any other reason other than weakness (e.g., patient declines, or patient's medical equipment prevents performance of the task), then do not score.

Wheelchair Mobility

Does the patient need assistance to propel a manual wheelchair on level surfaces for 150 feet (45 m)?

[Testing Note: Assisting with managing medical equipment (i.e. IV poles, cardiac monitoring, etc.) while the patient is performing wheelchair mobility should not be considered as a second person assisting with the task]

No:

Can the patient safely propel a manual wheelchair 150 feet (45 m) without any supervision or physical assist? If yes, score 6.

Yes:

Does the patient require only supervision or cueing in order to safely propel a manual wheelchair 150 feet (45 m) without physical help? If yes, score 5.

Can the patient safely propel a wheelchair a minimum of 150 feet (45 m) with only occasional minimal assistance (defined as the patient being able to perform more than 75% of the task) of one person for help, such as with turning or negotiating thresholds? If yes, score 4.

Can the patient safely propel a wheelchair for a minimum of 150 feet (45 m) with moderate assistance of only one person (defined as the patient being able to perform between 50 to 74% of the task)? If yes, score 3.

Can the patient safely propel a manual wheelchair at least 50 feet (15 m) with the assistance of only one person? If yes, score 2.

Can the patient safely propel a manual wheelchair less than 50 feet (15 m) with the assist of one person or requires the assistance of two people to physically assist with any wheelchair mobility distance? If yes, score 1.

Is the patient unable to attempt or complete the task of wheelchair mobility due to weakness? If yes, score 0.

If task(s) were not performed for any other reason other than weakness (e.g., patient declines, or patient's medical equipment prevents performance of the task), then do not score.

Task 1 (Rolling): -

Task 2 (Supine to Sit): -

Task 3 (Sit to Stand): -

Task 4 (Sitting Edge): -

Task 5 (Walking): -

Wheelchair Mobility: -

TOTAL SCORE (Tasks 1-5): -