Step-by-Step Coding Guide for Item Set GG0170J3: Walk 50 Feet with Two Turns (Discharge Performance)

1. Review of Medical Records

Objective: Assess the resident's ability to walk 50 feet with two turns at discharge, utilizing medical records and direct observation.

• Examine the resident's medical and therapy records focusing on mobility assessments, progress notes, and any changes in the resident's condition or mobility status since admission.
• Identify any interventions, such as physical therapy, that may have impacted the resident's ability to perform the walking task.

2. Understanding Definitions

• Walk 50 Feet with Two Turns: This item measures the resident's ability to walk 50 feet and make two turns. A turn is defined as a change in direction of 90 degrees or more without stopping or sitting.
• Discharge Performance: The resident's performance of the task at the time of discharge from the facility or care unit.

3. Coding Instructions

• Code 06 - Independent: The resident completes the task without any type of assistance.
• Code 05 - Set-up or clean-up assistance: The resident requires help only with setting up or cleaning up after the task.
• Code 04 - Supervision or touching assistance: The resident requires verbal cues, supervision, or light touch assistance to perform the task.
• Code 03 - Partial/moderate assistance: The helper does less than half the effort required for the resident to perform the task.
• Code 02 - Substantial/maximal assistance: The helper does more than half the effort.
• Code 01 - Dependent: The resident does not perform any part of the task.
• Code 07 - Resident refused: The task was not completed because the resident refused to attempt it.
• Code 09 - Not applicable: The resident is not able to walk.
• Code 88 - Not attempted due to medical condition or safety concerns: The task was not attempted due to medical conditions or safety concerns.

4. Coding Tips

• Ensure the environment is safe and free of obstacles.
• Observe the resident using their usual assistive device, if applicable.
• Assess the resident's ability to safely perform the task, considering balance, strength, and endurance.

5. Documentation

• Document the resident's performance, noting the use of assistive devices and the level of assistance provided.
• Record any relevant observations regarding the resident's gait, speed, and ability to make turns.
• Include information on any changes in the resident's performance compared to previous assessments.

6. Common Errors to Avoid

• Failing to observe the resident's performance throughout the entire task.
• Misinterpreting the use of assistive devices as independence.
• Not considering the resident's safety and comfort during the assessment.

7. Practical Application

• Use the results of this assessment to guide discharge planning, including recommendations for home modifications, need for assistive devices, and follow-up care.
• Provide feedback to the resident and family members about the resident's mobility status and progress.

The Step-by-Step Coding Guide for item GG0170J3 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.