Step-by-Step Coding Guide for Item Set GG0170I3: Walk 10 Feet (Discharge Performance)

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1. Review of Medical Records

• Objective: Ascertain the resident's capability to walk 10 feet at discharge.
• Key Points:
  • Review the resident’s medical records, focusing on nursing assessments, physical and occupational therapy evaluations, and care plans for information regarding the resident’s ability to walk 10 feet.
  • Look for progress notes that detail improvements or regressions in walking ability throughout the resident's stay, with a particular focus on the period leading up to discharge.

2. Understanding Definitions

• Objective: Clarify the activity "Walk 10 Feet."
• Key Points:
  • Walk 10 Feet: Refers to the resident's ability to walk 10 feet in a straight line. This includes initiating the walk, maintaining balance, and stopping, with or without the use of assistive devices or human assistance.

3. Coding Instructions

• Objective: Accurately document the resident's discharge performance in walking 10 feet.
• Key Points:
  • Use the following scale to code 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 walking 10 feet observed near the discharge date.
• Assess the entire process of walking, including any required assistive devices and whether the resident needed verbal cues for safety.

5. Documentation

• Objective: Ensure thorough documentation to support the coding decision.
• Key Points:
  • Document observations regarding the resident's ability to walk 10 feet, including any assistance required, use of equipment, or environmental adaptations.
  • Record any relevant conditions affecting the resident's walking ability and interventions aimed at improving this function.

6. Common Errors to Avoid

• Overlooking the resident's use of assistive devices or environmental modifications when coding, potentially misrepresenting the resident's level of independence.
• Failing to document improvements or declines in walking ability observed during the stay.

7. Practical Application

• Scenario: Mrs. Angela Martinez showed significant improvement in her ability to walk 10 feet by discharge, progressing from needing substantial assistance to requiring only a cane for support. Physical therapy notes highlight her steady gains in strength and balance. Therefore, she is coded as 5 (setup or clean-up assistance) in GG0170I3, reflecting her use of a cane for walking 10 feet.

The Step-by-Step Coding Guide for item GG0170I3 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.