Step-by-Step Coding Guide for Item Set GG0170FF3: Tub/Shower Transfer (Discharge Performance)

This guide will assist in accurately coding and documenting a resident's discharge performance in tub/shower transfers, as specified in item GG0170FF3 of the MDS 3.0.

1. Review of Medical Records

• Objective: Ascertain the resident's ability to safely transfer in and out of a tub or shower at discharge.
• Key Points:
  • Review the resident’s medical history, focusing on physical and occupational therapy evaluations, nursing assessments, and care plans related to the resident’s ability to transfer to and from a tub or shower.
  • Note any progress notes indicating improvements or declines in the resident's transfer abilities throughout their stay, especially close to the discharge date.

2. Understanding Definitions

• Objective: Define "Tub/Shower Transfer."
• Key Points:
  • Tub/Shower Transfer: Involves the resident's ability to move into and out of a tub or shower area safely. This includes stepping over the tub wall, maintaining balance while standing or sitting to shower, and exiting the area safely, with or without the use of assistive devices or human assistance.

3. Coding Instructions

• Objective: Document the resident's discharge performance in tub/shower transfers accurately.
• Key Points:
  • Use the following scale to code tub/shower transfer performance:
    • 6: Independent
    • 5: Setup or clean-up assistance
    • 4: Supervision or touching assistance
    • 3: Partial/moderate assistance
    • 2: Substantial/maximal assistance
    • 1: Dependent
  • Code 88 if the activity was not attempted during the assessment period.

4. Coding Tips

• Base the coding on the resident’s most dependent episode of tub/shower transfer near the discharge date.
• Ensure that any use of assistive devices or environmental modifications is considered when determining the level of independence.

5. Documentation

• Objective: Ensure comprehensive documentation of the resident's discharge performance in tub/shower transfers.
• Key Points:
  • Record observations about the resident's process of transferring to and from the tub or shower, including any assistance required and the use of equipment or modifications.
  • Document the resident's progress in transfer abilities, interventions used to enhance these abilities, and any remaining challenges at discharge.

6. Common Errors to Avoid

• Not capturing improvements in the resident’s ability to transfer to and from the tub/shower because of not reviewing the most current assessments.
• Misinterpreting the use of grab bars or shower chairs as full dependence without considering the resident's actual need for human assistance.

7. Practical Application

• Scenario: Mr. David Lee, who was initially dependent on two staff members for tub/shower transfers due to balance issues, showed significant improvement in his ability to transfer with minimal assistance by discharge. His occupational therapy notes highlight his progression to using only a grab bar for stabilization. Thus, he is coded as 3 (partial/moderate assistance) in GG0170FF3, reflecting his improved but still assisted transfer ability.

The Step-by-Step Coding Guide for item GG0170FF3 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.