Step-by-Step Coding Guide for Item Set GG0170L3: Walking 10 Feet on Uneven Surfaces (Discharge Performance)

1. Review of Medical Records

Objective: Assess the resident's ability to walk 10 feet on uneven surfaces at the point of discharge, utilizing a detailed review of medical records.

• Examine physical therapy assessments, nursing notes, and physician orders specifically mentioning the resident's ability to navigate uneven surfaces.
• Highlight any mobility aids used during the stay and note improvements or changes in the resident's balance or walking ability since admission.

2. Understanding Definitions

• Walking 10 Feet on Uneven Surfaces: This activity requires the resident to walk over surfaces that are not flat or smooth, such as gravel or grass, challenging their balance and walking skills.
• Discharge Performance: Reflects how the resident performs the task at the time of discharge, indicating their mobility status upon leaving the facility.

3. Coding Instructions

• Code 06 - Independent: Resident completes the task without any help, using no verbal cues or physical assistance.
• Code 05 - Set-up or clean-up assistance: Resident needs help only in preparing or finishing the task.
• Code 04 - Supervision or touching assistance: Requires verbal guidance or steadying support but not full physical assistance.
• Code 03 - Partial/moderate assistance: Helper does less than half the effort required for the resident to accomplish the task.
• Code 02 - Substantial/maximal assistance: Helper provides more than half the effort.
• Code 01 - Dependent: Resident cannot participate in the task; full assistance is needed.
• Code 07 - Resident refused: The task was not attempted because the resident refused.
• Code 09 - Not applicable: The resident's condition does not allow for walking.
• Code 88 - Not attempted due to medical condition or safety concerns: Health or safety risks prevented the attempt.

4. Coding Tips

• Ensure the area used for assessment mimics real-life uneven surfaces the resident might encounter.
• Conduct the assessment using the resident’s regular mobility aid, if any, documenting its use.
• Observe the resident’s entire performance, noting any hesitancy or adjustments made.

5. Documentation

• Detail the resident's ability to complete the task, including any assistance or aids used.
• Make observations about the resident’s gait, pace, and any difficulties faced during the walk.
• Compare the performance at discharge to that at admission to document progress or decline.

6. Common Errors to Avoid

• Misinterpreting the need for verbal or supervision assistance as independence.
• Overlooking the significance of the resident's use of an assistive device in their ability to perform the task.
• Inadequate preparation of the assessment area, leading to an unrepresentative evaluation of the resident's capabilities.

7. Practical Application

• Use the assessment results to tailor the resident's discharge plan, focusing on their ability to navigate various terrains safely.
• Coordinate with physical therapy and the care team to ensure any needed support or equipment is available for the resident post-discharge.

The Step-by-Step Coding Guide for item GG0170L3 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.