|Instrument Name||Scoring Criteria|
|Activities of Daily Living (ADL) Screen||
18 patient independent|
6 patient very independent
|Functional Independence Measure (FIM)||
5-Supervision or step-up;
4-Minimal Contact Assistance;
|Katz index ADL||
Score of 6 = High, Patient is independent.|
Score of 0 = Low, patient is very dependent.
ADL: 70–100 = Independent;|
Less than 70 = Needs significant physical/supervisory assistance.
|Instrumental activities of daily living (IADL)||
2 = without assistance,|
1 = with assistance,
0 = unable
|Instrumental activities of daily living (IADL) scale (Lawton) / IADL Screen||
The total score may range from 0 to 8.|
A lower score indicates a higher level of dependence.
|Functional Activity Questionnaire (FAQ)||Score of 5 or more indicates significant impairment in instrumental activities of daily living.|
|Morse fall scale / Annual Fall Scale / MRT||
> = 45: high fall risk|
25–44: moderate risk
0–24: low risk
|Tinetti assessment measures||
Maximum possible balance score: 16 points.|
Maximum possible gait score: 12 points.
Maximum total score: 28 points. -Scores below 19 indicate high risk for falls.
Scores in the 19–24 range indicate some risk for falls.
Pressure Ulcer Risk:|
total score < =9 very high risk
total score 10–12 high risk
total score 13–14 moderate risk|
total score 15–18 mild risk
total score 19–23 no risk