Step-by-Step Coding Guide for Item Set GG0170P3: Picking Up Object (Discharge Performance)

1. Review of Medical Records

Objective: Evaluate the resident's ability to pick up an object from the floor at discharge, through detailed examination of medical and therapy records.

• Action Steps: Review physical and occupational therapy evaluations, nursing documentation, and physician notes that focus on the resident's mobility, dexterity, and balance. Highlight progress in these areas and any remaining challenges.

2. Understanding Definitions

• Picking Up Object: Tests the resident's ability to bend down and pick up an object from the floor, assessing balance, lower body strength, and flexibility.
• Discharge Performance: Reflects the resident's current level of ability to perform this task at the time of discharge, offering insight into progress made during their stay.

3. Coding Instructions

• Code 06 - Independent: Completes the task without assistance, including the use of adaptive or assistive devices.
• Code 05 - Set-up or clean-up assistance: Needs help only in preparing or concluding the task.
• Code 04 - Supervision or touching assistance: Requires verbal guidance or light touch support for safety.
• Code 03 - Partial/moderate assistance: Helper does less than half the effort required for the task.
• Code 02 - Substantial/maximal assistance: Helper provides more than half the effort.
• Code 01 - Dependent: Full assistance needed; the resident does not participate.
• Code 07 - Resident refused: The resident declines to perform the task.
• Code 09 - Not applicable: The resident's condition precludes performing the task.
• Code 88 - Not attempted due to medical condition or safety concerns: Health or safety risks prevented the attempt.

4. Coding Tips

• Use an object of standard size and weight for consistency in the assessment.
• Ensure the resident is in a safe environment and wearing appropriate footwear for the task.
• Observe and consider the entire process, including the resident's strategy, execution, and return to an upright position.

5. Documentation

• Document the resident's method of performing the task, any assistance used, and the use of assistive devices.
• Record detailed observations regarding the resident’s technique, effort, and any balance or mobility issues.
• Compare discharge performance with admission assessment to document progress or areas needing ongoing support.

6. Common Errors to Avoid

• Overlooking the importance of verbal guidance or steadying assistance as a form of aid.
• Assuming the use of assistive devices means the resident cannot perform the task independently.
• Insufficient documentation that lacks details on how the resident performed the task and the level of assistance required.

7. Practical Application

• Utilize the assessment results to inform the resident's discharge plan, focusing on safety and independence in daily activities.
• Collaborate with the care team to ensure appropriate follow-up care or interventions are arranged, enhancing the resident's ability to safely perform similar tasks at home.

The Step-by-Step Coding Guide for item GG0170P3 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.