Step-by-Step Coding Guide for Item Set GG0170E5: Chair/Bed-to-Chair Transfer (OBRA/Interim Performance)

This guide is intended to provide a comprehensive approach to accurately code and document a resident's performance in chair/bed-to-chair transfers during an OBRA or interim performance assessment period, as outlined in item GG0170E5 of the MDS 3.0.

1. Review of Medical Records

• Objective: Determine the resident's ability to perform chair/bed-to-chair transfers during the OBRA/interim assessment period.
• Key Points:
  • Review nursing assessments, physical and occupational therapy evaluations, and care plans for descriptions of the resident’s ability to transfer between a bed and a chair or wheelchair.
  • Pay attention to documentation on the use of assistive devices or the need for assistance from staff or caregivers.

2. Understanding Definitions

• Objective: Define "Chair/Bed-to-Chair Transfer."
• Key Points:
  • Chair/Bed-to-Chair Transfer: Involves moving from a lying position in bed to a sitting position in a chair or wheelchair, and vice versa. It includes actions such as sitting up, standing (if applicable), and sitting down, with or without assistance.

3. Coding Instructions

• Objective: Accurately document the resident's OBRA/interim performance in transferring.
• Key Points:
  • Utilize the standard coding scale for functional abilities and goals:
    • 6: Independent
    • 5: Setup or clean-up assistance
    • 4: Supervision or touching assistance
    • 3: Partial/moderate assistance
    • 2: Substantial/maximal assistance
    • 1: Dependent
  • Code as 88 if the activity was not attempted during the assessment period.

4. Coding Tips

• Base coding on observations of the resident's most dependent episode of performing the transfer during the assessment period.
• Consider the resident's consistent need for assistance or use of devices, ensuring accurate reflection in coding.

5. Documentation

• Objective: Maintain comprehensive documentation to support the coding decision.
• Key Points:
  • Document detailed observations of the resident’s transfer process, including any required assistance and the use of equipment or devices.
  • Include notes on the resident’s progress or regression in transfer abilities and interventions aimed at improving this function.

6. Common Errors to Avoid

• Failing to account for occasional assistance needs when coding, leading to overestimation of the resident's independence.
• Not updating the resident’s records and coding based on the most current assessment information.

7. Practical Application

• Scenario: During the interim OBRA assessment, Ms. Sofia Rodriguez required partial assistance to safely transfer from her bed to her wheelchair due to decreased lower limb strength. Physical therapy notes indicate that she has made some progress with strengthening exercises but still requires hands-on assistance for safe transfers. Based on this, Ms. Rodriguez is coded as 3 (partial/moderate assistance) in GG0170E5.

The Step-by-Step Coding Guide for item GG0170E5 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.