Step-by-Step Coding Guide for Item Set GG0170Q3: Use of Wheelchair/Scooter (Discharge Performance)

1. Review of Medical Records

Objective: Assess the resident's ability to use a wheelchair or scooter at the time of discharge through a comprehensive review of medical records.

• Action Steps: Look into documentation from physical and occupational therapy assessments, nursing notes, and physician orders focused on the resident's mobility status, especially their use and handling of a wheelchair or scooter. Take note of any improvements, persisting challenges, or changes in the type of mobility aid used during their stay.

2. Understanding Definitions

• Use of Wheelchair/Scooter: Evaluates the resident's skill in safely and effectively operating a manual or electric wheelchair or scooter.
• Discharge Performance: Indicates the resident's level of independence and proficiency in using a wheelchair or scooter at discharge, highlighting progress or need for continued support.

3. Coding Instructions

• Code 06 - Independent: Resident independently operates the wheelchair or scooter, navigating various spaces without assistance.
• Code 05 - Set-up or clean-up assistance: Resident operates the device independently but requires assistance for setting up or storing the device.
• Code 04 - Supervision or touching assistance: Requires verbal cues, supervision, or light touch assistance to ensure safe operation.
• Code 03 - Partial/moderate assistance: Helper provides less than half the effort required.
• Code 02 - Substantial/maximal assistance: Helper contributes more than half the effort.
• Code 01 - Dependent: Resident is fully dependent on assistance to use the wheelchair or scooter.
• Code 07 - Resident refused: The resident declined to use the wheelchair or scooter.
• 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: Operation was not attempted due to health or safety reasons.

4. Coding Tips

• Consider assessing the resident in various environments within the facility to understand their range of ability.
• Take into account both the resident's manual dexterity (for electric scooters) and physical capability (for manual wheelchairs).
• Pay special attention to the resident's ability to safely maneuver, including starting, stopping, turning, and navigating tight spaces.

5. Documentation

• Clearly document the type of wheelchair or scooter used, noting any specific features or adaptations.
• Record observations of the resident's ability to operate the device, including any assistance required or difficulties encountered.
• Highlight the resident's progress since admission in terms of mobility aid use.

6. Common Errors to Avoid

• Neglecting to observe the resident in a variety of settings and conditions that mimic real-life scenarios.
• Misinterpreting the need for setup assistance or supervision as full independence.
• Failing to document the assessment comprehensively, including detailed descriptions of the resident's operation of the device.

7. Practical Application

• Use the discharge assessment findings to inform post-discharge planning, focusing on ensuring the resident's safety and independence in their next environment.
• Coordinate with therapists and the care team to recommend any necessary modifications or training for the resident or caregivers on wheelchair or scooter use.

The Step-by-Step Coding Guide for item GG0170Q3 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.