Step-by-Step Coding Guide for Item Set GG0170G3: Car Transfer (Discharge Performance)

This comprehensive guide is designed to help accurately code and document a resident's discharge performance in car transfers, as specified in item GG0170G3 of the MDS 3.0.

1. Review of Medical Records

• Objective: Determine the resident's ability to safely transfer in and out of a car at discharge.
• Key Points:
  • Examine the resident’s medical history, focusing on nursing assessments, physical and occupational therapy evaluations, and care plans for information about the resident’s ability to perform car transfers.
  • Look for progress notes detailing the resident's ability to sit down into and stand up from a car seat, including the use of assistive devices or the need for assistance.

2. Understanding Definitions

• Objective: Clarify "Car Transfer."
• Key Points:
  • Car Transfer: Refers to the ability to move into and out of a car seat. This includes sitting down into the car seat from a standing position and standing up from the car seat to exit the car, which may require assistance or the use of assistive devices.

3. Coding Instructions

• Objective: Accurately document the resident's discharge performance in car transfers.
• Key Points:
  • Utilize the following scale to code car 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 did not occur during the assessment period.

4. Coding Tips

• Base the coding on the resident’s most dependent episode of car transfer observed near the discharge date.
• Remember to account for any environmental modifications or assistive devices and how they impact the resident’s level of independence.

5. Documentation

• Objective: Ensure comprehensive documentation of the resident's discharge performance in car transfers.
• Key Points:
  • Record detailed observations about the resident's process of transferring to and from the car, including any required assistance and the use of equipment or modifications.
  • Document the resident's progress or regression in ability to transfer compared to admission performance.

6. Common Errors to Avoid

• Failing to recognize and document the use of assistive devices as a form of independence.
• Not updating the resident's records with the most current assessment data.

7. Practical Application

• Scenario: At discharge, Ms. Rebecca Smith, who initially needed substantial assistance for car transfers due to a hip replacement, demonstrated significant improvement after rehabilitation. She could independently lower herself into the car seat and exit the car with only a grab bar for support. Thus, she is coded as 6 (independent) in GG0170G3.

The Step-by-Step Coding Guide for item GG0170G3 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.