Step-by-Step Coding Guide for Item Set GG0170N1: 4 Steps (Curb) (Admission Performance)

1. Review of Medical Records

Objective: Assess the resident's ability to navigate 4 steps at admission, utilizing a thorough review of medical records.

• Review physical therapy evaluations, nursing assessments, and physician's orders, focusing on mobility, specifically the ability to manage steps.
• Note any conditions affecting balance or strength, and identify any mobility aids used.

2. Understanding Definitions

• 4 Steps (Curb): This item evaluates the resident's ability to ascend and descend a series of four steps, assessing balance, coordination, and lower extremity strength.
• Admission Performance: Reflects the resident's capability to manage steps at the time of admission, establishing a baseline for mobility.

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 in preparing or concluding the activity.
• Code 04 - Supervision or touching assistance: The resident needs verbal cues or light touch support to maintain balance or for safety.
• 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: The resident cannot perform the task; full assistance is required.
• Code 07 - Resident refused: The resident declines to perform the task.
• Code 09 - Not applicable: The resident is unable to perform the task due to functional limitations.
• 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 steps used for assessment are standard in height and safe for the resident to navigate.
• Conduct the assessment using the resident's regular assistive device, if applicable, and note its use.
• Observe the resident's entire performance, including the approach to the steps, the action of stepping up and down, and moving away from the steps.

5. Documentation

• Document the resident's performance in ascending and descending the steps, including any assistance or aids used.
• Note observations about the resident's balance, the effort exerted, and any difficulties encountered.
• Compare the resident's performance to previous assessments if available, to track changes or improvements in mobility.

6. Common Errors to Avoid

• Not considering the use of assistive devices as a form of assistance.
• Overlooking the need for verbal guidance or physical steadying as indications of less than independent performance.
• Incomplete documentation that fails to capture detailed observations of the resident's performance.

7. Practical Application

• Use the assessment results to develop a targeted care plan, focusing on improving mobility and safety in navigating steps.
• Discuss the findings with the interdisciplinary team to coordinate care and interventions, such as physical therapy, to enhance the resident's ability to manage steps.

The Step-by-Step Coding Guide for item GG0170N1 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.