Step-by-Step Coding Guide for Item Set GG0110D: Walker

This guide provides a comprehensive approach for accurately coding and documenting the use of a walker as specified in item GG0110D of the MDS 3.0.

1. Review of Medical Records

• Objective: Identify the resident's use of a walker.
• Key Points:
  • Examine the resident's medical records for mentions of walker use, including physical therapy assessments, physician's notes, and nursing care plans.
  • Look for specific evaluations that recommend the use of a walker for mobility or documentation of the resident's preference for a walker.

2. Understanding Definitions

• Objective: Clarify what is meant by "Walker."
• Key Points:
  • Walker: A mobility aid used by residents who need additional support to maintain balance or stability while walking. Walkers can vary in design, including standard walkers without wheels and rollators with wheels.

3. Coding Instructions

• Objective: Provide guidance on accurately coding the use of a walker.
• Key Points:
  • Code "1" if the resident uses a walker during the assessment period.
  • Code "0" if the resident does not use a walker.

4. Coding Tips

• Confirm the current use of a walker, as a resident's mobility needs may have changed since the last assessment.
• Distinguish between occasional and regular use of a walker; if the walker is part of the resident's primary mobility aids, it should be coded as "1."

5. Documentation

• Objective: Ensure comprehensive documentation regarding walker use.
• Key Points:
  • Document the assessment that led to the recommendation for a walker, including the date and the healthcare professional's name.
  • Record any resident training or instruction provided on the proper use of the walker, including adjustments for fit and safety.

6. Common Errors to Avoid

• Assuming a resident does not need a walker without checking recent therapy assessments or ignoring resident preferences.
• Failing to recognize the use of different types of walkers for different mobility needs (e.g., standard vs. rollator).

7. Practical Application

• Scenario: Mrs. Emily Johnson, a resident in the facility, has been using a rollator walker for the past six months as documented in her physical therapy notes. Her care plan reflects the need for a walker to support her mobility due to partial paralysis following a stroke. During the MDS assessment period, staff consistently document Mrs. Johnson's use of her rollator for all ambulation activities within the facility. The MDS Coordinator reviews this information and codes "1" for GG0110D, accurately reflecting her reliance on a walker for mobility.

The Step-by-Step Coding Guide for item GG0110D in MDS 3.0 Section GG is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.