Step-by-Step Coding Guide for Item Set GG0170F5: Toilet Transfer (OBRA/Interim Performance)

This guide provides detailed instructions for accurately coding and documenting a resident's performance in toilet transfers during an OBRA or interim assessment period, as outlined in item GG0170F5 of the MDS 3.0.

1. Review of Medical Records

• Objective: Ascertain the resident's ability to transfer to and from the toilet during the OBRA or 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 to and from the toilet.
  • Pay special attention to documentation on the use of assistive devices or the need for assistance from staff or caregivers.

2. Understanding Definitions

• Objective: Define "Toilet Transfer."
• Key Points:
  • Toilet Transfer: Involves the resident's ability to move safely to and from the toilet, which may include standing up from a seated position, moving from a wheelchair or other device to the toilet, and vice versa, with or without the use of assistive devices or human assistance.

3. Coding Instructions

• Objective: Accurately document the resident's OBRA/interim performance in toilet transfers.
• 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.
• Ensure that any use of assistive devices is accurately reflected in the coding.

5. Documentation

• Objective: Maintain comprehensive documentation to support the coding decision.
• Key Points:
  • Record detailed observations about the resident's process of transferring to and from the toilet, noting any assistance required and the use of equipment or modifications.
  • Document any relevant conditions affecting the resident’s ability to perform toilet transfers and any 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 based on the most current assessment information.

7. Practical Application

• Scenario: During the interim OBRA assessment period, Mr. Thomas Wilson required partial assistance to safely transfer to and from the toilet due to decreased lower limb strength following surgery. Physical therapy notes indicate improvements in his strength, but he still requires hands-on assistance for safe transfers. Based on this, Mr. Wilson is coded as 3 (partial/moderate assistance) in GG0170F5.

The Step-by-Step Coding Guide for item GG0170F5 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.