Step-by-Step Coding Guide for Item Set GG0170P1: Picking Up Object (Admission Performance)

1. Review of Medical Records

Objective: Evaluate the resident's ability to pick up an object from the floor at admission, using a comprehensive review of medical and therapy records.

• Action Steps: Examine documentation from physical and occupational therapy assessments, nursing notes, and physician orders related to the resident's fine motor skills, balance, and flexibility. Note any conditions or disabilities that might impact their ability to bend or reach.

2. Understanding Definitions

• Picking Up Object: This activity assesses the resident's capability to bend or stoop to pick up an object from the floor, testing their lower body strength, balance, and flexibility.
• Admission Performance: Indicates the resident's level of ability to perform this task at the time of admission, establishing a baseline for their mobility and dexterity.

3. Coding Instructions

• Code 06 - Independent: Resident completes the task without any help, using no adaptive or assistive devices.
• Code 05 - Set-up or clean-up assistance: Assistance required only before or after the task.
• Code 04 - Supervision or touching assistance: The resident needs verbal cues or light touch support to maintain balance.
• Code 03 - Partial/moderate assistance: Helper does less than half the effort.
• Code 02 - Substantial/maximal assistance: Helper provides more than half the effort.
• Code 01 - Dependent: Resident cannot perform the task; full assistance is required.
• Code 07 - Resident refused: Resident declined to perform the task.
• Code 09 - Not applicable: The resident's condition precludes them from performing 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

• Use a standardized object for the assessment to maintain consistency.
• Ensure the resident wears appropriate footwear and the assessment area is safe.
• Observe the resident’s entire process, including approach, execution, and recovery posture.

5. Documentation

• Clearly document the resident's performance, including any assistance provided and the use of assistive devices.
• Note any observations related to the resident’s balance, effort, and technique used.
• Record any adverse reactions or difficulties encountered during the task.

6. Common Errors to Avoid

• Failing to recognize the significance of verbal cues or physical steadying as assistance.
• Incorrectly coding a resident as independent without considering the use of adaptive devices.
• Inadequate documentation that lacks detail about the resident’s performance and the assistance level required.

7. Practical Application

• Use the assessment results to tailor the resident’s care plan, focusing on improving mobility, balance, and lower body strength.
• Incorporate findings into therapy goals, such as physical or occupational therapy, to enhance the resident's ability to perform similar tasks safely.

The Step-by-Step Coding Guide for item GG0170P1 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.