Step-by-Step Coding Guide for Item Set GG0170M3: 1 Step (Curb) (Discharge Performance)

1. Review of Medical Records

Objective: Evaluate the resident's ability to navigate a single step or curb at the time of discharge, using a comprehensive review of medical and therapy records.

• Examine therapy evaluations, nursing notes, and physician orders that document the resident's mobility status, focusing on their ability to manage steps or curbs.
• Note any mobility aids used and the progression of the resident's mobility skills during their stay.

2. Understanding Definitions

• 1 Step (Curb): This activity requires the resident to step up and down a single step or curb, testing their balance, strength, and coordination.
• Discharge Performance: Reflects the resident's current ability to perform the task at the time of discharge, indicating improvements or declines in mobility.

3. Coding Instructions

• Code 06 - Independent: Resident completes the task without assistance, including no use of physical support or verbal cues.
• 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 light touch support for balance or steadying.
• Code 03 - Partial/moderate assistance: Helper does 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 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 stepping up or down.
• Code 88 - Not attempted due to medical condition or safety concerns: Health or safety reasons precluded the attempt.

4. Coding Tips

• Ensure the step or curb used for assessment is standard in height, mimicking real-life conditions.
• Assess using the resident’s usual mobility aid if applicable, noting its use in the documentation.
• Observe the entire process, including approach, execution, and departure from the step.

5. Documentation

• Detail the resident's ability to manage the step, including any assistance or aids used.
• Make note of observations regarding the resident’s balance, effort, and any hesitation or difficulty encountered.
• Compare the performance at discharge to that at admission to document progress or need for continued intervention.

6. Common Errors to Avoid

• Misinterpreting the use of verbal cues or supervision as independence.
• Not considering the use of assistive devices in assessing the resident’s performance.
• Inadequately documenting the resident's approach, execution, and departure from the step.

7. Practical Application

• Utilize the assessment results to guide discharge planning, focusing on the resident's ability to navigate their home environment safely.
• Collaborate with physical therapy to ensure any needed supports or interventions are included in the discharge plan.

The Step-by-Step Coding Guide for item GG0170M3 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.