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

1. Review of Medical Records

• Objective: Ensure comprehensive and accurate documentation of the resident’s ability to pick up an object at discharge.
• Steps:
  1. Collect Medical Records: Gather all relevant medical records, including therapy notes, nursing notes, and previous assessments.
  2. Identify Relevant Information: Focus on documentation that describes the resident's ability to pick up objects, fine motor skills, and upper body strength.
  3. Consult with Care Team: Discuss with the interdisciplinary team, including occupational therapists, to get a complete picture of the resident’s performance.

2. Understanding Definitions

• Picking up Object: Refers to the resident's ability to bend, reach, and pick up an object, such as a small item from the floor, while maintaining balance and control.
• Discharge Performance: The level of assistance required by the resident to perform this task at the time of discharge from the facility.

3. Coding Instructions

• Steps:
  1. Assessment: Evaluate the resident's ability to pick up an object at discharge. This should be based on direct observation and input from therapy staff.
  2. Performance Level: Determine the resident's performance using the following scale:
     • 06: Independent
     • 05: Setup or clean-up assistance
     • 04: Supervision or touching assistance
     • 03: Partial/moderate assistance
     • 02: Substantial/maximal assistance
     • 01: Dependent
  3. Enter Code: Record the appropriate code that matches the resident’s level of performance at discharge.

4. Coding Tips

• Direct Observation: Whenever possible, directly observe the resident performing the task to ensure accurate assessment.
• Therapy Input: Use detailed reports from occupational or physical therapists who have worked closely with the resident.
• Consistency: Ensure consistency in coding by cross-referencing with other related assessments and progress notes.

5. Documentation

• Required:
  • Therapy Notes: Document the resident’s progress and performance during therapy sessions.
  • Observation Records: Include direct observations of the resident picking up objects.
  • Care Plans: Record interventions and strategies used to improve or support the resident’s ability to pick up objects.

6. Common Errors to Avoid

• Inconsistent Documentation: Ensure all records and assessments are consistent with the observed performance.
• Assumption Without Observation: Avoid coding based on assumptions or incomplete information; direct observation is crucial.
• Ignoring Variations: Consider any fluctuations in performance and document the resident's best, consistent level of function.

7. Practical Application

• Example:
  • Resident Profile: John Doe, a 75-year-old male recovering from hip surgery.
  • Steps:
    1. Review Records: Collect therapy and nursing notes, previous assessments, and progress reports.
    2. Assess Performance: Observe John picking up a small object from the floor with minimal assistance.
    3. Consult Care Team: Discuss with John's physical therapist who confirms John needs supervision but can perform the task.
    4. Rate Performance: Based on observation and therapist input, John is rated as requiring supervision (04).
    5. Enter Code: Document code 04 in item set GG0170P3 to reflect John’s discharge performance.

Please note that the information provided in this guide for MDS 3.0 Item set GG0170P3 was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.