Step-by-Step Coding Guide for Item Set GG0170O3: 12 Steps (Discharge Performance)

1. Review of Medical Records

Objective: Assess the resident's ability to navigate 12 steps at the point of discharge, using a thorough review of medical and therapy records.

• Action Steps: Examine documentation from physical and occupational therapy assessments, nursing notes, and physician orders that detail the resident's mobility, specifically their ability to manage stairs. Highlight any changes in mobility aids used and note improvements or challenges encountered since admission.

2. Understanding Definitions

• 12 Steps: This activity assesses the resident's capability to ascend and descend a flight of 12 steps, which tests lower limb strength, balance, and coordination.
• Discharge Performance: Indicates the resident's current level of ability to perform this task at discharge, reflecting any progress made during their stay.

3. Coding Instructions

• Code 06 - Independent: The resident completes the task without any assistance or supervision.
• Code 05 - Set-up or clean-up assistance: The resident needs help only in preparing or concluding the task.
• Code 04 - Supervision or touching assistance: The resident requires verbal cues or light touch assistance for balance or navigation.
• Code 03 - Partial/moderate assistance: The helper provides less than half the effort required for the task.
• Code 02 - Substantial/maximal assistance: The helper provides more than half the effort.
• Code 01 - Dependent: The resident cannot perform the task; the helper does all the work.
• Code 07 - Resident refused: The resident declined to perform the task.
• Code 09 - Not applicable: The resident's condition precludes them from attempting the task.
• Code 88 - Not attempted due to medical condition or safety concerns: The task was not attempted due to health or safety risks.

4. Coding Tips

• Ensure the staircase used for the assessment is safe and similar to what the resident might encounter in their daily environment.
• If the resident uses a mobility aid, include it in the assessment and document its use.
• Observe the resident’s technique in navigating the steps, including their approach, execution, and departure from the staircase.

5. Documentation

• Clearly document the resident's performance in ascending and descending the 12 steps, including any assistance provided and the use of mobility aids.
• Record observations about the resident’s gait, effort, and any hesitancy or difficulty encountered.
• Compare the discharge performance with the admission assessment to note improvements or areas needing continued intervention.

6. Common Errors to Avoid

• Overlooking the need for verbal cues or steadying assistance as a form of support.
• Assuming the use of an assistive device automatically implies the resident cannot be coded as independent.
• Incomplete documentation that lacks detail on how the resident navigates the steps.

7. Practical Application

• Utilize the discharge assessment to guide post-discharge planning, especially focusing on the resident's safety in their home environment or the need for further therapy.
• Share assessment results with the care team, the resident, and their family to ensure understanding of the resident's current mobility status and any recommendations for safety modifications at home.

The Step-by-Step Coding Guide for item GG0170O3 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.