Step-by-Step Coding Guide for Item Set GG0170J5: Walk 50 Feet with Two Turns (OBRA/Interim Performance)

1. Review of Medical Records

Objective: Evaluate the resident's ability to walk 50 feet with two turns during the OBRA or interim performance assessment period through a thorough review of medical records.

• Compile data from therapy assessments, nursing notes, and physician orders that pertain to mobility, focusing on any changes since the last evaluation.
• Pay special attention to notes indicating the use of assistive devices or modifications in mobility.

2. Understanding Definitions

• Walk 50 Feet with Two Turns: The task involves the resident walking 50 feet and making two turns of about 90 degrees each, without the need to sit down during the process.
• OBRA/Interim Performance: Performance assessed at a specified OBRA or during an interim period, reflecting the resident's current mobility status.

3. Coding Instructions

• Code 06 - Independent: Resident completes the task without assistance.
• Code 05 - Set-up or clean-up assistance: Assistance required only before or after the task.
• Code 04 - Supervision or touching assistance: Verbal cues or steadying support needed.
• Code 03 - Partial/moderate assistance: Helper provides less than half the effort.
• Code 02 - Substantial/maximal assistance: Helper provides more than half the effort.
• Code 01 - Dependent: Complete assistance required; resident does not participate.
• Code 07 - Resident refused: Resident chose not to attempt the task.
• Code 09 - Not applicable: Resident is unable to walk.
• Code 88 - Not attempted due to medical condition or safety concerns: Task not attempted for health or safety reasons.

4. Coding Tips

• Observe the entire performance, noting how the resident navigates turns and uses any assistive devices.
• Assess in a safe, familiar environment to the resident, ensuring freedom from hazards.

5. Documentation

• Detail the resident's performance, including the type of assistance or assistive device used.
• Note any observations relevant to the resident's balance, gait, and confidence during the task.

6. Common Errors to Avoid

• Incorrectly coding a resident as independent without considering the need for verbal cues or supervision.
• Overlooking the use of assistive devices as part of the resident's regular mobility strategy.
• Failing to document the assessment comprehensively.

7. Practical Application

• Apply findings to develop or adjust care plans, specifically targeting mobility improvements or maintenance strategies.
• Use assessment outcomes to inform interdisciplinary discussions on resident care, particularly for physical therapy interventions.

The Step-by-Step Coding Guide for item GG0170J5 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.