Step-by-Step Coding Guide for Item Set GG0170N3: 4 Steps (Curb) (Discharge Performance)

1. Review of Medical Records

Objective: Evaluate the resident's ability to navigate four steps at discharge by reviewing their medical records comprehensively.

• Action Steps: Examine physical and occupational therapy assessments, nursing documentation, and physician's notes focusing on mobility, specifically the resident's progress in managing steps. Note any use of assistive devices or modifications in their mobility status since admission.

2. Understanding Definitions

• 4 Steps (Curb): This activity involves the resident ascending and descending four steps, testing balance, lower limb strength, and coordination.
• Discharge Performance: Indicates the resident's capability to perform the activity at the point of discharge, reflecting their current level of functional mobility.

3. Coding Instructions

• Code 06 - Independent: Resident completes the activity without any assistance.
• Code 05 - Set-up or clean-up assistance: Assistance needed only before or after the activity.
• Code 04 - Supervision or touching assistance: Verbal cues or light steadying support required.
• 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: Resident does not contribute to the activity; helper does all the work.
• Code 07 - Resident refused: Resident declined to perform the activity.
• Code 09 - Not applicable: Resident is incapable of performing the activity due to functional limitations.
• Code 88 - Not attempted due to medical condition or safety concerns: Activity was not attempted due to the resident's condition or safety issues.

4. Coding Tips

• Ensure the steps are of standard height and the area is safe for assessment.
• If the resident uses an assistive device, include it in the assessment and note its use.
• Observe and document the resident's entire interaction with the steps, paying close attention to their technique and safety.

5. Documentation

• Document the resident's performance in detail, including the type of assistance provided or required and the use of any assistive devices.
• Record any observed challenges or difficulties the resident encounters, such as balance issues or hesitation.
• Highlight improvements or declines in performance compared to the initial assessment upon admission.

6. Common Errors to Avoid

• Not recognizing the significance of verbal guidance or physical steadying as assistance.
• Failing to document the use of an assistive device or incorrectly assuming its use equates to dependence.
• Incomplete documentation that lacks detail on the resident's interaction with the steps.

7. Practical Application

• Utilize assessment results to inform post-discharge planning, focusing on safety and independence in the home environment.
• Collaborate with the care team to ensure appropriate follow-up care, such as outpatient therapy or home modifications, is arranged.

The Step-by-Step Coding Guide for item GG0170N3 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.