GG0170Q5. Use wheelchair/scooter (OBRA/Interim Performance), Step-by-Step

Step-by-Step Coding Guide for Item Set: GG0170Q5. Use Wheelchair/Scooter (OBRA/Interim Performance)

1. Review of Medical Records

   • Start by thoroughly reviewing the resident's medical records, focusing on any documentation related to their mobility, specifically their ability to use a wheelchair or scooter. Look for physician's orders, physical therapy notes, nursing assessments, and any other relevant information that outlines the resident's current abilities and limitations.

2. Understanding Definitions

   • Wheelchair/Scooter: Any manual or power-driven device designed to convey a person who has difficulty with walking or mobility.
   • OBRA: Omnibus Budget Reconciliation Act, which includes regulations for nursing home care.
   • Interim Performance: The resident's current ability to use a wheelchair or scooter, considering any recent changes in their condition.

3. Coding Instructions

   • For GG0170Q5, code the resident's ability based on direct observation or reliable reports from staff who are familiar with the resident's capabilities. Use the following scale to determine the appropriate code:
     • 09: Independent - Resident completes the activity by themselves with no assistance.
     • 05: Setup or clean-up assistance - Resident needs help before or after the task.
     • 04: Supervision or touching assistance - Resident requires verbal cues or light physical support.
     • 03: Partial/moderate assistance - Helper does less than half the effort.
     • 02: Substantial/maximal assistance - Helper does more than half the effort.
     • 01: Dependent - Helper does all of the effort.
     • 88: Activity not attempted due to medical condition or safety concerns.

4. Coding Tips

   • Observe the resident or consult with caregiving staff to determine the most accurate code. Consider factors such as the resident's ability to safely maneuver the wheelchair/scooter, need for physical support, and whether the resident initiates the activity independently.

5. Documentation

   • Record your coding decision in the MDS and support it with detailed notes in the resident's medical record. Describe the resident's ability, the type of assistance required, and any observed challenges or safety concerns.

6. Common Errors to Avoid

   • Overestimating the resident's independence - Ensure observations are accurate.
   • Not considering the resident's need for supervision or verbal cues.
   • Failing to document reasons when the activity is not attempted.

7. Practical Application

   • Example: Mrs. Smith uses a power wheelchair due to severe arthritis. She can independently operate the wheelchair but needs help adjusting the footplates before transferring. The appropriate code would be 05 (Setup or clean-up assistance).

The Step-by-Step Coding Guide for item GG0170Q5 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.