BIMS Form – Fill Out and Use This PDF

In C0100, enter 0 for No (resident is rarely/never understood), then skip to and complete C0700-C1000, Staff Assessment for Mental Status.

In C0100, enter 1 for Yes, then continue to C0200, Repetition of Three Words.

In C0200, ask the resident to repeat the three words sock, blue, and bed after you have said all three, then enter the number of words repeated after the first attempt.

In C0200, enter 0 for None, 1 for One, 2 for Two or 3 for Three.

After the resident's first attempt, repeat the words using cues (sock, something to wear; blue, a color; bed, a piece of furniture). You may repeat the words up to two more times.

For C0300A, ask the resident to tell you what year it is right now. Enter 0 if missed by > 5 years or no answer, 1 if missed by 2-5 years, 2 if missed by 1 year or 3 if correct.

For C0300B, ask the resident what month it is right now. Enter 0 if missed by > 1 month or no answer, 1 if missed by 6 days to 1 month or 2 if accurate within 5 days.

For C0300C, ask the resident what day of the week it is today. Enter 0 if incorrect or no answer or 1 if correct.

In C0400, ask the resident what the three words were that you asked the resident to repeat. If the resident is unable to remember a word, give the cue (something to wear; a color; a piece of furniture) for that word.

For C0400A, able to recall sock: enter 0 for No - could not recall, 1 for Yes, after cueing (something to wear) or 2 for Yes, no cue required.

For C0400B, able to recall blue: enter 0 for No - could not recall, 1 for Yes, after cueing (a color) or 2 for Yes, no cue required.

For C0400C, able to recall bed: enter 0 for No - could not recall, 1 for Yes, after cueing (a piece of furniture) or 2 for Yes, no cue required.

In C0500, add scores for questions C0200-C0400 and fill in the total score (00-15). Enter 99 if the resident was unable to complete the interview.