By Amy Niemas, RN-BC, BSN, MSW, Clinical Content Director · Psychiatric Registered Nurse

Last updated: October 13, 2026

How to Score and Document the Barthel Index (Nursing Guide)

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Why This Matters

Regulatory bodies: Centers for Medicare & Medicaid Services (CMS) - Section GG Functional Abilities and Goals, CMS Minimum Data Set (MDS) 3.0 - Skilled Nursing Facility Quality Reporting, CMS OASIS - Home Health Quality Reporting

Mahoney and Barthel published the Barthel Index in 1965, based on their work in Maryland chronic disease hospitals. It became the most studied ADL (activities of daily living) measure in rehabilitation, especially for stroke patients. In 1989, Shah, Vanclay, and Cooper expanded the scoring, because the original steps were too generalized to capture the small functional gains that matter week to week in stroke rehabilitation. Functional scores are not just paperwork; they drive rehab goals, discharge destinations, caregiver training plans, and level-of-care decisions. In addition, the trend from admission to discharge is key in decision making. As with any scoring tool, the total score is important. However, the breakdown of scoring for each individual item, and the resulting trends, is essential for evaluating patient care needs.
  1. Functional evaluation: the Barthel Index — Mahoney FI, Barthel DW. Md State Med J. 1965;14:61-65 (1965)
  2. Improving the sensitivity of the Barthel Index for stroke rehabilitation — Shah S, Vanclay F, Cooper B. J Clin Epidemiol. 1989;42(8):703-709 (1989)
  3. The Barthel ADL Index: a reliability study — Collin C, Wade DT, Davies S, Horne V. Int Disabil Stud. 1988;10(2):61-63 (1988)
  4. Barthel Index - psychometrics, populations, and scoring reference — Shirley Ryan AbilityLab, Rehabilitation Measures Database (2024)
  5. Barthel Index (BI) - versions and Shah 5-level scoring — Strokengine, Canadian Partnership for Stroke Recovery (2024)
  6. Barthel Index for Activities of Daily Living (ADL) - online calculator — MDCalc (2026)
  7. MDS Section G: Functional Status replaced with Section GG: Functional Abilities and Goals — CMS QIES Technical Support Office (2023)

What the Barthel Index Measures and When to Use It

The Barthel Index consists of 10 items which assess independence in the basic activities of daily living (ADLs): feeding, bathing, grooming, dressing, bowel control, bladder control, toilet use, transfers, mobility on level surfaces, and stairs. The total score ranges from 0 to 100 in the original version, with higher scores indicating greater independence. It is validated most heavily in stroke rehabilitation and is also used in geriatrics, post-acute rehab, long-term care, and home health. Two rules define the instrument. First, the index records what the patient actually did over the preceding 24 to 48 hours, rather than what they might manage on a good day. Second, the need for supervision indicates that the patient is not independent for that item. For example, a patient who showers safely only because someone stands in the doorway does not earn the independent score. It is important to note that the Barthel Index does not measure every possible area of dependence or independence. Instead, it focuses on basic self-care and mobility, while excluding items for cooking, medications, finances, or any other instrumental ADLs, as well as the areas of cognition or communication. A perfect score of 100 means independence in these 10 tasks, but it does not guarantee safety to live alone. It is a tool to be used as part of an overall assessment. The score remains reliable whether derived from a patient self-report, a nurse who has worked with the patient for a shift, or direct observation by a trained observer (Collin et al, 1988).

The 10 Barthel Items and Their Point Values

The original Barthel Index scores each item in 5-point increments: 0, 5, 10, or 15, depending on the item. A middle score indicates that the patient needed some assistance but completed more than half the work themselves.

Feeding (0, 5, or 10)

Score 10 when the patient feeds themselves at a reasonable pace once food is within reach, including using utensils and spreading butter. Score 5 when they need help with tasks like cutting meat or opening containers, but otherwise feed themselves. Score 0 when they cannot feed themselves. A modified diet does not lower the score by itself; this item focuses on who does the work of eating.

Bathing (0 or 5)

Score 5 only when the patient gets in and out of the bath or shower and washes without another person present. Score 0 for any hands-on help or supervision. This item applies the supervision rule most strictly, as standby assistance in the shower is nearly universal after a stroke or fall. Charting example: "Bathing 0. Showered with standby supervision for safety."

Grooming (0 or 5)

Score 5 when the patient washes their face, combs their hair, brushes their teeth, and shaves independently. You can provide implements, such as handing them the razor. Score 0 when they need help with any of these tasks.

Dressing (0, 5, or 10)

Score 10 when the patient dresses independently, including buttons, zippers, and shoes. Score 5 when they need help, but complete at least half the work themselves in a reasonable time. Score 0 when they are fully dependent. It is important to note that the use of adaptive equipment that the patient manages alone, such as a buttonhook or elastic laces, still counts as independent.

Bowel Control (0, 5, or 10)

Score 10 when the patient is continent. Score 5 for occasional accidents, or when they need help with an enema or suppository. Score 0 when they are incontinent. Score the actual pattern over the observed time period, not just the best day this week.

Bladder Control (0, 5, or 10)

Score 10 when the patient is continent, or manages their own catheter or other collection device independently. Score 5 for occasional accidents. Score 0 when they are incontinent, or when they are catheterized and unable to manage the device themselves.

Toilet Use (0, 5, or 10)

Score 10 when the patient gets on and off the toilet, manages clothing, wipes, and flushes without help. Score 5 when they need some assistance, but can complete part of the task alone. Score 0 when they are dependent. Toilet use and the two continence items are separate: for example, a continent patient who needs help with clothing before/after toileting scores 10 on bladder control, but scores 5 on toilet use.

Transfers, Bed to Chair and Back (0, 5, 10, or 15)

Score 15 when the transfer is independent. Score 10 for minor help, whether verbal cueing or light physical assistance. Score 5 when the patient needs major help from one or two people, but can sit unsupported. Score 0 when they cannot transfer and have no sitting balance. This is one of the two most heavily weighted items on the scale, so a change here affects the overall total more than a change in most other categories.

Mobility on Level Surfaces (0, 5, 10, or 15)

Score 15 when the patient walks 50 yards or more independently; a cane or other walking aid is allowed. Score 10 when they walk 50 yards or more with the help of one person. Score 5 when they cannot walk, but can propel a wheelchair independently for at least 50 yards. Score 0 when they are immobile or cover less than 50 yards. The distance threshold is part of the definition, so it is very important to chart the distance observed.

Stairs (0, 5, or 10)

Score 10 when the patient goes up and down a flight of stairs independently; a walking aid is allowed if it can be managed independently. Score 5 when they need help or supervision, whether verbal or physical, or need assistance using their walking aid. Score 0 when they are unable to complete without total assistance. In facilities without accessible stairs, this item often comes from the physical therapy note, which is a legitimate source, just make sure to chart the source.

The 5-point Modified Barthel Index (Shah version)

When someone says the 5-point Barthel Index, they almost always mean the Modified Barthel Index published by Shah, Vanclay, and Cooper in 1989. It keeps the same 10 items, but rates each one on a 5-level scale: 1 (unable to perform the task), 2 (attempts the task but is unsafe), 3 (moderate help required), 4 (minimal help required), and 5 (fully independent). Each level corresponds to a weighted point value for that item, so the total still runs 0 to 100 and stays comparable with the original. Shah created the modified scale to allow for nuances in progress. For example, a stroke patient who progresses from needing two people for a transfer to needing one is genuinely better, but the original scale may not change at all; the 5-level version catches that gain. Shah also published the interpretation bands which most facilities use for the 0 to 100 total: 0-20 suggests total dependence, 21-60 severe dependence, 61-90 moderate dependence, 91-99 slight dependence, and 100 independence. One more version exists that is important to recognize. The Collin version, which is common in the United Kingdom and in research, rescores the same 10 items on a 0 to 20 total. A charted "Barthel 18" is near-independence on the Collin scale and profound dependence on the 0 to 100 scale, which is why it is essential to note which version of the scale is being used.

How to Score at the Bedside

First, set your evidence window. Score the index based on actual performance over the preceding 24 to 48 hours. Your sources include your observations, reports from the aide(s) who provided morning care, other providers, therapy notes, and input from the patient and family. Collin's reliability study found these sources closely agree, so do not be afraid to use these differing sources; just be sure to note it in your charting. Next, review the 10 items with the published definitions in front of you, such as the printed scoring sheet or the official MDCalc calculator (a free online clinical calculator, linked in this guide's sources), and then assign each item the score that matches the patient's actions. Two tie-breakers resolve most difficult calls. If the patient needed supervision, they are not independent, so drop from the top score. If they needed help, determine who did more than half the work: if the patient did more than half, assign the middle score; if the helper did more, lower the score. Avoid averaging a good morning against a bad evening. Score the pattern that held for the longest time during the window. If performance genuinely fluctuated, document the changes in your narrative, as that variability provides clinical information. The whole assessment takes about five minutes once the definitions and nuances become familiar.

How to Document a Barthel Index Score

A complete Barthel entry includes five elements: the version used, all 10 item scores, the total score, a comparison with the prior score, and the next steps based on the results. Charting example: "1400 Barthel Index (original 0-100 version): feeding 5, bathing 0, grooming 5, dressing 5, bowel control 10, bladder control 5, toilet use 5, transfers 10, mobility 10 (walked 50 yards in hallway with rolling walker and assistance from one), stairs 0. Total 55, up from 35 on admission. Gains in transfers and ambulation per PT treatment this week. Recommend to continue assistance from one for toileting; and to implement a toileting schedule overnight for bladder accidents." Note what the entry does. The version makes the total interpretable. The item scores show where the 55 comes from; a 55 built on continence and feeding describes a different patient than a 55 built on mobility. The distance and assistance level under mobility show the evidence behind the score rather than a bare number. And the trend and plan turn the score into something the care conference and the SBAR handoff can act on. A simple "Barthel 55" without these details is the functional equivalent of saying "ambulated well," which only gives a cursory view of the patient's overall level of functioning.

The Barthel Index and CMS Section GG (when applicable)

In a post-acute setting in the United States regulated by the Centers for Medicare & Medicaid Services (CMS), your facility must submit functional documentation through Section GG: Functional Abilities and Goals. You should be alerted to this requirement and be directed as to specific charting. This section includes standardized self-care and mobility items found in the Skilled Nursing Facility (SNF) Minimum Data Set (MDS), the inpatient rehab patient assessment, the long-term care hospital data set, and home health OASIS (Outcome and Assessment Information Set). Effective October 1, 2023, Section GG fully replaced the old MDS Section G. Unfortunately, the Barthel Index does not meet these new requirements and cannot be directly translated. GG items assess the helper effort required for each task on a 6-level scale with specific definitions, making it impossible to copy a Barthel item score into a GG item. Mapping between them is a judgment call, not something to do on the fly. So where does the Barthel Index still fit? Stroke and rehab programs use it to track functional recovery, because decades of research define what a meaningful change looks like. Research protocols and international records use it as a common language. And some facilities keep it in their admission and discharge assessments by policy. The practical rule: document Section GG items according to the GG definitions when the assessment window requires them, and chart the Barthel Index separately when your facility uses it, each under its own name.

ADL Documentation in NurseChartingPro

NurseChartingPro does not currently include a structured Barthel Index field. However, in NCP clinical charting, the head-to-toe assessment and Morse Fall Scale include many of these items. If completing a full Barthel Index, include all information (version, 10 item scores, total, trend, plan) in the Notes & Education category to ensure the generated narrative reflects it. NCP's psychiatric charting has a dedicated Function & Daily Living category that covers ADL independence observationally, without a numeric scale. Either way, the habit that the Barthel Index teaches, detailing itemized scores along with supporting evidence, transfers to any documentation system, and is essential to good nursing practice.

Common Mistakes

Scoring What the Patient Could Do Instead of What They Did

Weak: Mobility 15. Patient is able to walk independently with his walker.
Strong: Mobility 10. Walked 50 yards in the hallway with a rolling walker and assistance from one staff member this shift; notable improvement as the patient has not walked unassisted since admission.

The Barthel Index scores actual performance over the preceding 24 to 48 hours, not capacity. Claims like "is able to" reflect capacity rather than actual events. If the patient did not walk unassisted during this time, the independent score overstates function, inflates the total, and can create a discharge plan the patient cannot meet.

Charting Only the Total Score

Weak: Barthel 55.
Strong: Barthel Index (original 0-100 version): feeding 5, bathing 0, grooming 5, dressing 5, bowel control 10, bladder control 5, toilet use 5, transfers 10, mobility 10, stairs 0. Total: 55.

Two patients with the same total score can have very different issues. A score of 55 based on intact continence and poor mobility requires a different care plan than a 55 based on independent ambulation with incontinence. The item scores provide clinically useful information; the total serves only as a summary.

Counting Supervised Performance as Independent

Weak: Bathing 5, independent. Nurse remained in bathroom during shower.
Strong: Bathing 0. Showered self with standby supervision for safety; supervision means not independent for this item.

Supervision is a scoring criterion, not a footnote. If someone must be present for the task to occur safely, the patient is not independent for that item. Scoring it as independent conceals a genuine safety dependency from the next reader and the discharge planner, as well as creates a potentially unsafe situation for the patient.

Charting a Total Without Naming the Version

Weak: Barthel 18 this morning.
Strong: Barthel ADL Index (Collin 0-20 version): 18/20. The patient lost one point each in bathing and stairs.

An 18 indicates near-independence on the Collin 0 to 20 scale, but reflects profound dependence on the 0 to 100 scale. The same score can describe two patients requiring completely different levels of care. Always name the version and include the denominator when your facility uses the 0 to 20 form.

Substituting a Barthel Score for Section GG Items (if applicable)

Weak: Section GG: see Barthel score above.
Strong: Strong charting would include completion of Section GG self-care and mobility items according to GG definitions in the MDS, as well as documentation of the Barthel Index score of 55 separately to track trends.

Section GG items have specific task definitions and a unique helper-effort rating scale. CMS mandates their use during post-acute assessment windows. Do not copy a Barthel score into GG items. Maintain the integrity of both instruments by charting each under its respective name.

Case Example

Mr. DelgadoAge 71 — Right middle cerebral artery ischemic stroke with left-sided weakness, inpatient rehabilitation day 10
fictional patient

Scenario

You are the day nurse on an inpatient rehab unit. Mr. Delgado is 10 days out from a right MCA stroke with residual left-sided weakness. His admission Barthel Index was 35. The interdisciplinary care conference meets tomorrow to set his discharge plan, and the weekly Barthel assessment is due on your shift. This morning the aide provided standby supervision while he showered. He fed himself at breakfast and brushed his teeth and shaved himself. He dressed himself except for his left shoe and sock, and in PT he walked the hallway (50 yards) with a rolling walker and one person assisting (other scores/reports are included below).

Chart Entry

1400 Barthel Index (original 0-100 version), scored from this shift and the prior 24 hours based on direct observation, CNA report, and PT note:

Feeding 5 (feeds self; meat cut for him at breakfast and lunch)
Bathing 0 (showered self with standby supervision)
Grooming 5 (brushed teeth and shaved with an electric razor independently)
Dressing 5 (dressed self except for left shoe and sock; more than half of the task self-performed)
Bowel control 10 (continent for 72 hours)
Bladder control 5 (one urinary accident overnight per CNA report)
Toilet use 5 (needs help with clothing management; wipes and flushes self)
Transfers 10 (moved from bed to standing in front of walker with some assistance, holding arm while getting up from bed, and verbal cues)
Mobility 10 (walked 50 yards in the hallway with a rolling walker and assist of one, PT at 1000)
Stairs 0 (not yet attempted per PT)

Total 55, up from 35 on admission (remains in severe dependence band, trending toward moderate). Largest gains in transfers and ambulation. Plan: continue assist of one for toileting and transfers, toileting schedule overnight for bladder accidents, stairs training per PT this week. Will present trend at care conference.

Key points from above chart entry

Version and evidence sources named up front:
The entry names the original 0-100 version and the scoring sources (observation, CNA report, PT note), so any reader can reproduce the score. Collin's reliability work is what makes those secondhand sources legitimate.
Every item score carries its evidence:
Each parenthetical states what was observed, not just the number. "Walked the hallway for 50 yards with a rolling walker and one person assisting" is much more detailed than the score by itself. Think of the difference between that and just charting "mobility 10".
Supervision scored as dependent:
Bathing scores 0 even though Mr. Delgado washed himself, as standby supervision was required.
Trend and band, not just a total:
The comparison to admission (35 to 55) and the band label (trending from severe to moderate) turn a number into a recovery trajectory the care conference can act on.
The score ends in a plan:
Assist levels, the overnight toileting schedule, and future stairs training all derive from specific item scores. These scores guide the next steps in intervention and care planning.

Pro Tips

  • Score each item from the published definitions, not from memory: Keep the printed scoring sheet or the official calculator in front of you. Match the patient's actions to the exact wording of each level. Paraphrased scoring can drift between raters, and the week-over-week trend holds meaning only if every rater scores against the same definitions.
  • Use the last 24 hours as your evidence window: You did not watch this patient bathe, dress, and toilet today, and you did not have to. Ask the aide who provided morning care, read the therapy note, ask other providers/staff members, and ask the patient and family. Research on reliability shows that these sources align with direct observation. The evidence window excludes scoring based on memory from last week or "drive-by" hallway impressions.
  • The middle score hinges on who does more than half the work: A middle score indicates that the patient needed assistance but still completed most of the task. If the helper performed the majority of the work, lower the score. If the patient did more than the helper, increase the score. Asking "Who did more than half?" out loud clarifies nearly every borderline decision, and the aide can answer this question precisely.
  • Name the version each time you chart a total: Original 0-100, Modified (Shah) 5-level, or Collin 0-20. The same patient can score 55 on the 0-100 scale and 11 on the 0-20 scale on the same day. Not writing which version is used leads to significant misinterpretation. If your facility uses the 0-20 version, write the denominator into the entry: 18/20 is much less likely to be misread than just an unnamed 18.
  • A score of 100 does not mean the patient can live alone: The Barthel Index focuses solely on basic self-care and mobility. It does not address cooking, medication management, finances, driving, cognition, or judgment. Document a perfect score when the patient achieves it, and ensure the discharge-readiness conversation includes instrumental ADLs and the cognitive aspects that the Barthel Index does not evaluate.

Step by Step

  1. Confirm the version your facility uses: Original 0-100, Modified (Shah) 5-level, or Collin 0-20. Write the version into your entry before you score anything; the totals are not interchangeable.
  2. Set the evidence window: Gather information from the past 24 to 48 hours, including your observations, the aide's report from morning care, therapy notes, and feedback from the patient and family.
  3. Score all 10 items from the published definitions: Match the observed performance to the exact wording of each level. Use the two tie-breakers: supervision indicates the patient is not independent, and assign the middle score to the patient who completed more than half the work.
  4. Total the score and identify the band: Sum the 10 items. On the 0 to 100 scale: 0-20 total dependence, 21-60 severe dependence, 61-90 moderate dependence, 91-99 slight dependence, 100 total independence.
  5. Chart the itemized entry with trend and plan: Chart the version, all 10 item scores with their evidence, the total, the change from the prior score, and the subsequent care-plan actions.

Frequently Asked Questions

What is the Barthel Index?
The Barthel Index measures independence in 10 basic activities of daily living: feeding, bathing, grooming, dressing, bowel control, bladder control, toilet use, transfers, mobility, and stairs. Mahoney and Barthel developed this index in 1965, and it remains one of the most studied functional measures in stroke and geriatric rehabilitation. The original version scores from 0 to 100, with higher scores indicating greater independence.
What is the 5-point Barthel Index?
The 5-point Barthel Index usually refers to the Modified Barthel Index published by Shah, Vanclay, and Cooper in 1989. It keeps the original 10 items but rates each on 5 levels, from unable to perform the task through fully independent, with weighted point values that keep the total on the 0 to 100 scale. The finer steps make it more sensitive to the small functional gains that matter in stroke rehabilitation.
What Barthel Index score indicates independence?
On the 0 to 100 scale, a score of 100 indicates independence in all 10 items. The commonly used bands are 0-20 for total dependence, 21-60 for severe dependence, 61-90 for moderate dependence, and 91-99 for slight dependence. In the Collin version, the maximum score is 20. A perfect score reflects independence in basic self-care and mobility only. The index does not assess cooking, medications, finances, or cognition, so it cannot determine if a patient is safe to live alone.
Is the Barthel Index required by CMS?
No, the Centers for Medicare & Medicaid Services (CMS) does not require the Barthel Index. In CMS-regulated post-acute settings, Section GG: Functional Abilities and Goals is the required functional documentation. This section replaced Minimum Data Set (MDS) Section G effective October 1, 2023, and appears across skilled nursing, inpatient rehab, long-term care hospital, and home health assessments. The Barthel Index serves as a supplementary clinical tool. Facilities and stroke programs may still use it for trend tracking, and it remains standard in research and in many countries outside the United States.
Who can score the Barthel Index?
Nurses, therapists, and physicians can all score the Barthel Index; no licensure restrictions apply. The 1988 Collin reliability study found that patient self-reports, nurses who worked with the patient during a shift, and trained observers produced closely agreeing scores. Your facility policy determines who documents the official score. Anyone scoring it should refer to the published item definitions and the patient's actual performance within the last 24 to 48 hours.
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