DRS Syllabus

ITEM DEFINITIONS

Eye opening

0	SPONTANEOUS: eyes open with sleep/wake rhythms indicating active and arousal mechanisms; does not assume awareness.
1	TO SPEECH AND/OR SENSORY STIMULATION: a response to any verbal approach, whether spoken or shouted, not necessarily the command to open the eyes. Also, response to touch, mild pressure.
2	TO PAIN: tested by a painful stimulus.( Standard painful stimulus is the application of pressure across index fingernail of best side with wood or a pencil; for quadriplegics pinch nose tip and rate as 0, 1, 2 or 5.)
3	NONE: no eye opening even to painful stimulation.

Best communication ability (if patient cannot use voice because of tracheostomy or is aphasic or dysarthric or has vocal cord paralysis or voice dysfunction then estimate patient's best response and enter note under comments.)

0	ORIENTED: implies awareness of self and the environment. Patient able to tell you a) who he is; b) where he is; c) why he is there; d) year; e) season; f) month; g) day; h) time of day.
1	CONFUSED: attention can be held and patient responds to questions but responses are delayed and/or indicate varying degrees of disorientation and confusion.
2	INAPPROPRIATE: intelligible articulation but speech is used only in an exclamatory or random way (such as shouting and swearing); no sustained communication exchange is possible.
3	INCOMPREHENSIBLE: moaning, groaning or sounds without recognizable words; no consistent communication signs.
4	NONE: no sounds or communication signs from patient.

Best motor response

0	OBEYING: obeying command to move finger on best side. If no response or not suitable try another command such as "move lips," "blink eyes," etc. Do not include grasp or other reflex responses.
1	LOCALIZING: a painful stimulus at more than one site causes a limb to move (even slightly) in an attempt to remove it. It is a deliberate motor act to move away from or remove the source of noxious stimulation. If there is doubt as to whether withdrawal or localization has occurred after 3 or 4 painful stimulations, rate as localization.
2	WITHDRAWING: any generalized movement away from a noxious stimulus that is more than a simple reflex response.
3	FLEXING: painful stimulation results in either flexion at the elbow, rapid withdrawal with abduction of the shoulder or a slow withdrawal with adduction of the shoulder. If there is confusion between flexing and withdrawing, then use pin prick on hands, then face.
4	EXTENDING: painful stimulation results in extension of the limb.
5	NONE: no response can be elicited. Usually associated with hypotonia. Exclude spinal transection as an explanation of lack of response; be satisfied that an adequate stimulus has been applied.

Cognitive ability for feeding, toileting and grooming.

Rate each of the three functions separately. For each function answer the question, does the patient show awareness of how and when to perform each specified activity. Ignore motor disabilities that interfere with carrying out a function, this is rated under Level of Functioning described below. Rate best response for toileting based on bowel and bladder behavior. Grooming refers to bathing, washing, brushing of teeth, shaving, combing or brushing of hair and dressing.

0	COMPLETE: continuously shows awareness that he knows how to feed, toilet or groom self and can convey unambiguous information that he knows when this activity should occur.
1	PARTIAL: intermittently shows awareness that he knows how to feed, toilet or groom self and/or can intermittently convey reasonably clearly information he knows when the activity should occur.
2	MINIMAL: shows questionable or infrequent awareness that he knows in a primitive way how to feed, toilet or groom self and/or shows infrequently by certain signs, sounds or activities that he is vaguely aware when the activity should occur.
3	NONE: shows virtually no awareness at any time that he knows how to feed, toilet or groom self and cannot convey information by signs, sounds, or activity that he knows when the activity should occur.

Level of functioning

0	COMPLETELY INDEPENDENT: able to live as he wishes, requiring no restriction due to physical, mental, emotional or social problems.
1	INDEPENDENT IN SPECIAL ENVIRONMENT: capable of functioning independently when needed requirements are met (mechanical aids).
2	MILDLY DEPENDENT: able to care for most of own needs but requires limited assistance due to physical, cognitive and/or emotional problems (e.g. needs non-resident helper).
3	MODERATELY DEPENDENT: able to care for self partially but needs another person at all times.
4	MARKEDLY DEPENDENT: needs help with all major activities and the assistance of another person at all times.
5	TOTALLY DEPENDENT: not able to assist in own care and requires 24-hour nursing care.

"Employability"

The psychosocial adaptability or "employability" item takes into account overall cognitive and physical ability to be an employee, homemaker or student. This determination should take into account considerations such as the following:

1. Able to understand, remember and follow instructions; 2. Can plan and carry out tasks at least at the level of an office clerk or in simple routine, repetitive industrial situations or can do school assignments; 3. Ability to remain oriented, relevant and appropriate in work and other psychosocial situations; 4. Ability to get to and from work or shopping centers using private or public transportation effectively; 5. Ability to deal with number concepts; 6. Ability to make purchases and handle simple money exchange problems; 7. Ability to keep track of time schedules and appointments.

0	NOT RESTRICTED: can compete in the open market for a relatively wide range of jobs commensurate with existing skills; or can initiate, plan, execute and assume responsibilities associated with homemaking; or can understand and carry out most age relevant school assignments.
1	SELECTED JOBS, COMPETITIVE: can compete in a limited job market for a relatively narrow range of jobs because of limitations of the type described above and/or because of some physical limitations; or can initiate, plan, execute and assume many but not all responsibilities associated with homemaking; or can understand and carry out many but not all school assignments.
2	SHELTERED WORKSHOP, NON-COMPETITIVE: cannot compete successfully in job market because of limitations described above and/or because of moderate or severe physical limitations; or cannot without major assistance initiate, plan, execute and assume responsibilities for homemaking; or cannot understand and carry out even relatively simple school assignments without assistance.
3	NOT EMPLOYABLE: completely unemployable because of extreme psychosocial limitations of the type described above; or completely unable to initiate, plan, execute and assume any responsibilities associated with homemaking; or cannot understand or carry out any school assignments.

Add eight ratings to obtain total DRS score.

Tips:

If in doubt, give the patient the benefit of the doubt.

Remember that feeding, toileting and grooming items are rated on cognitive ability to know how and when, not physical ability.

Unlike the FIM+FAM, a rating of 5 (totally dependent) on level of functioning means totally dependent.

Always use two independent raters when possible, and compare ratings after completed. If there is a one point discrepancy that cannot be resolved, mean the two ratings (a .5 score). If there is a discrepancy of 1.5 or more points, obtain additional information on the case and re-rate.

If a patient clinically falls between two ratings, rate in .5 increment (e.g. between 2 and 3 = 2.5)

Examples of .5 ratings:

An example of appropriate use of a .5 rating for the "Level of Functioning" item:

The patient requires set-up for all activities of daily living, including dressing, eating, grooming, etc. He can be left alone for 2-3 hours, but he needs more than a non-resident helper. Therefore he is more than mildly dependent (rating of 2). On the other hand, he does not need another person at all times, as he can be left alone for short periods, e.g. between lunch and dinner, and is therefore not moderately dependent (rating of 3). He falls between a rating of 2 and 3 and should be rated 2.5.

An example of appropriate use of a .5 rating for the "Employability" item:

The individual, upon being discharged from inpatient rehabilitation, was placed with his former employer, who modified the job requirements because of reduced performance after the TBI (rating of 1). The individual, had he had to start over with a new, unfamiliar job, may have been more suited for a non-competitive sheltered workshop environment (rating of 2), but is able to function successfully in his present position due to extenuating circumstances. He falls between a rating of 1 and 2 and should be rated 1.5.