Step-by-Step Coding Guide for Item Set GG0170L1: Walking 10 Feet on Uneven Surfaces (Admission Performance)

1. Review of Medical Records

Objective: Evaluate the resident's ability to walk 10 feet on uneven surfaces at admission.

• Thoroughly review physical therapy assessments, nursing notes, and physician's orders related to mobility, focusing on walking abilities, especially on uneven surfaces.
• Identify any prior mobility aids used and note any conditions that might affect balance or walking.

2. Understanding Definitions

• Walking 10 Feet on Uneven Surfaces: The task involves the resident walking a distance of 10 feet over a surface that is uneven, such as grass or gravel, which may require more balance and effort than walking on a flat surface.
• Admission Performance: The resident's ability to perform the task at the time of admission, reflecting their initial mobility status.

3. Coding Instructions

• Code 06 - Independent: Resident completes the task without any assistance, including verbal cues or physical support.
• Code 05 - Set-up or clean-up assistance: Resident performs the task with help only in preparing or concluding the activity.
• Code 04 - Supervision or touching assistance: Resident requires verbal encouragement or light touch assistance for balance.
• Code 03 - Partial/moderate assistance: Helper provides less than half the effort required for the resident to complete the task.
• Code 02 - Substantial/maximal assistance: Helper provides more than half the effort.
• Code 01 - Dependent: Resident is unable to participate in the walking task; helper does all the effort.
• Code 07 - Resident refused: The resident chooses not to perform the task.
• Code 09 - Not applicable: The resident is not capable of walking.
• Code 88 - Not attempted due to medical condition or safety concerns: The task was not attempted due to health or safety reasons.

4. Coding Tips

• Ensure the assessment area is safely set up and the uneven surface is appropriate for the assessment.
• Assess using the resident’s usual assistive device if applicable, and document its use.
• Observe and consider the resident's entire performance, including the start and completion of the task.

5. Documentation

• Record the resident's performance in detail, noting the use of assistive devices and the level of assistance provided.
• Document observations regarding the resident’s gait, balance, and any difficulties encountered.
• Note any comparison between the resident's reported previous ability and the current assessment.

6. Common Errors to Avoid

• Not recognizing the need for verbal cues or supervision as a form of assistance.
• Assuming use of an assistive device means the resident cannot be considered independent.
• Inadequately preparing the assessment area, leading to inaccurate assessment of the resident's abilities.

7. Practical Application

• Utilize the assessment results to inform care planning, particularly for mobility goals and interventions.
• Share assessment findings with the interdisciplinary team to adapt the care plan and address any identified needs for mobility support or safety measures.

The Step-by-Step Coding Guide for item GG0170L1 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.