Step-by-Step Coding Guide for Item Set: GG0170R1. Wheel 50 Feet with Two Turns (Admission Performance)

1. Review of Medical Records

   • Begin by thoroughly examining the resident's medical records, focusing on their mobility assessments, physical therapy evaluations, and nursing notes. Identify any information regarding the resident's ability to use a wheelchair, including any recent changes in their condition or mobility.

2. Understanding Definitions

   • Wheel 50 Feet with Two Turns: This item assesses the resident's ability to wheel themselves 50 feet and make two turns while seated in a wheelchair. This task measures mobility, strength, coordination, and spatial awareness.
   • Admission Performance: Refers to the resident's ability to perform the task at the time of admission to the facility.

3. Coding Instructions

   • Observe the resident or rely on accurate reports from staff to code the resident's performance. Use the following scale:
     • 06: Independent - Resident completes the task by themselves without any type of assistance.
     • 05: Setup or clean-up assistance - Resident completes the task but requires help before or after.
     • 04: Supervision or touching assistance - Resident needs verbal cues or light touch assistance.
     • 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 the effort.
     • 07: Resident refused the activity.
     • 09: Not applicable - Resident not assessed/unknown.
     • 88: Activity not attempted due to medical condition or safety concerns.

4. Coding Tips

   • Accurately gauge the resident's ability by considering their need for verbal cues, the degree of physical support required, and the resident's initiation of the task. Remember to observe or consult on the resident's ability to make the two turns as part of the task.

5. Documentation

   • Clearly document the coding choice in the resident's MDS and medical records. Note the resident's specific abilities, type of assistance required, and any safety concerns or barriers observed during the task.

6. Common Errors to Avoid

   • Misjudging the resident's need for supervision or physical assistance.
   • Overlooking the resident's partial contributions to the task.
   • Failing to document the task attempt or the reason for not attempting it, especially if it relates to medical or safety concerns.

7. Practical Application

   • Example: Mr. Jones, upon admission, can independently navigate his wheelchair but requires verbal reminders to perform the turns safely due to cognitive limitations. The appropriate code would be 04 (Supervision or touching assistance).

The Step-by-Step Coding Guide for item GG0170R1 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.