Step-by-Step Coding Guide for Item Set GG0170Q1: Use of Wheelchair/Scooter (Admission Performance)

1. Review of Medical Records

Objective: Assess the resident's ability to use a wheelchair or scooter at the time of admission by reviewing their medical records comprehensively.

• Action Steps: Examine documentation from physical and occupational therapy assessments, nursing notes, and physician orders focusing on the resident's mobility status, particularly their use of a wheelchair or scooter. Highlight any noted limitations or difficulties in operating the device.

2. Understanding Definitions

• Use of Wheelchair/Scooter: This item assesses the resident's ability to safely and effectively use a wheelchair or scooter, including manual and electric types, within the facility.
• Admission Performance: Reflects the resident's current capability to operate a wheelchair or scooter at the time of their admission, establishing a baseline for their mobility.

3. Coding Instructions

• Code 06 - Independent: The resident operates the wheelchair or scooter independently in all areas required.
• Code 05 - Set-up or clean-up assistance: The resident can operate the wheelchair or scooter but needs assistance with setting up or storing the device.
• Code 04 - Supervision or touching assistance: The resident requires verbal cues, supervision, or light touch assistance for safe operation.
• Code 03 - Partial/moderate assistance: The helper provides less than half the effort required for the resident to operate the device.
• Code 02 - Substantial/maximal assistance: The helper provides more than half the effort.
• Code 01 - Dependent: The resident is unable to operate the wheelchair or scooter; the helper does all the work.
• Code 07 - Resident refused: The resident declined to perform the task.
• Code 09 - Not applicable: The resident does not use or is not prescribed a wheelchair or scooter.
• Code 88 - Not attempted due to medical condition or safety concerns: The task was not attempted due to health or safety reasons.

4. Coding Tips

• Assess the resident's use of the wheelchair or scooter in various settings within the facility to evaluate versatility.
• Consider both manual dexterity for operating controls and physical ability to propel the device.
• Observe the resident's ability to navigate tight spaces, turn, and stop safely.

5. Documentation

• Document the type of wheelchair or scooter used (manual or electric) and any modifications or special features.
• Record detailed observations of the resident's ability to operate the device, including any difficulties encountered.
• Compare the resident's reported or observed capabilities with the assessment findings to ensure accuracy.

6. Common Errors to Avoid

• Assuming a resident is independent with their device without observing them navigate different terrains and obstacles.
• Overlooking the need for supervision or verbal cues for residents who may exhibit unsafe practices.
• Failing to document specific challenges the resident faces, such as difficulty with wheelchair transfers or managing slopes.

7. Practical Application

• Use assessment results to identify specific areas of need for rehabilitation goals, focusing on increasing the resident's independence and safety with the wheelchair or scooter.
• Inform the interdisciplinary care plan, including any necessary adjustments to the living environment or the need for adaptive equipment.

The Step-by-Step Coding Guide for item GG0170Q1 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.