Step-by-Step Coding Guide for Item Set GG0170A3: Roll Left and Right (Discharge Performance)

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s ability to roll left and right at the time of discharge.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including nursing notes, physical and occupational therapy reports, and previous assessments.
  2. Identify Rolling Performance: Look for documented assessments of the resident’s ability to roll left and right.
  3. Confirm Details: Verify the consistency of the resident’s rolling performance through various sources within the medical records.

2. Understanding Definitions

• Roll Left and Right: The ability of the resident to turn their body from one side to the other while lying in bed.
• Discharge Performance: The resident’s ability to perform this activity at the time of discharge from the facility.

3. Coding Instructions

• Steps:
  1. Observe the Activity: During the discharge assessment, observe the resident’s ability to roll left and right in bed.
  2. Determine Level of Assistance: Identify the amount of assistance the resident requires to complete the activity.
  3. Code Appropriately: Use the following scale to code the resident’s performance:
     • Code 01: Dependent - Helper does all of the effort.
     • Code 02: Substantial/maximal assistance - Helper does more than half the effort.
     • Code 03: Partial/moderate assistance - Helper does less than half the effort.
     • Code 04: Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance.
     • Code 05: Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity.
     • Code 06: Independent - Resident completes the activity by themselves without assistance.

4. Coding Tips

• Accurate Observation: Ensure that the assessment is conducted in a consistent and controlled environment to accurately observe the resident’s abilities.
• Clarify Instructions: Make sure the resident understands the instructions for the activity.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the resident’s performance.

5. Documentation

• Required:
  • Observation Notes: Document the observations made during the assessment, including the level of assistance provided.
  • Therapy Reports: Include assessments from physical and occupational therapy sessions that detail the resident’s mobility and ability to roll left and right.
  • Discharge Summary: Document the resident’s abilities and any assistance required at the time of discharge.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the resident’s ability through multiple observations.
• Incomplete Documentation: Make sure all relevant details about the resident’s rolling performance are thoroughly documented.
• Assumptions: Do not assume the resident’s abilities without proper documentation and observation.

7. Practical Application

• Example:
  • Resident Profile: John, an 85-year-old resident, is being assessed for his ability to roll left and right in bed at the time of discharge.
  • Steps:
    1. Observe Performance: The nurse observes John as he rolls left and right in bed.
    2. Identify Assistance Level: John requires moderate assistance to roll from his back to his left and right sides.
    3. Document and Code: The nurse documents John’s performance as requiring partial/moderate assistance and codes GG0170A3 as "03".
  • Outcome: John’s ability to roll left and right is accurately documented and coded, ensuring proper follow-up and care planning.

Please note that the information provided in this guide for MDS 3.0 Item set GG0170A3 was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.