Step-by-Step Coding Guide for Item Set: GG0170R3. Wheel 50 Feet with Two Turns (Discharge Performance)

1. Review of Medical Records

   • Carefully examine the resident's medical records to assess their mobility progression, focusing on physical therapy reports, nursing notes, and other relevant documentation that reflects their ability to maneuver a wheelchair. Pay particular attention to any changes noted since admission and leading up to discharge.

2. Understanding Definitions

   • Wheel 50 Feet with Two Turns: This measure evaluates the resident's capacity to self-propel in a wheelchair for a distance of 50 feet and execute two turns.
   • Discharge Performance: The resident's level of ability to perform the task at the time of discharge from the facility.

3. Coding Instructions

   • Observe the resident performing the task, or gather accurate reports from staff who have observed the resident. Use the following scale for coding:
     • 06: Independent - No helper needed; the resident completes the task alone.
     • 05: Setup or clean-up assistance - The resident needs help before or after the task.
     • 04: Supervision or touching assistance - The resident requires verbal cues or steadying 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 - The resident requires full assistance to perform the task.
     • 88: Not attempted due to medical condition or safety concerns.

4. Coding Tips

   • Ensure accuracy by considering all aspects of the resident's ability, including their initiative to start the task, any verbal or physical assistance needed, and their ability to safely complete the two turns.

5. Documentation

   • Clearly document the selected code in the MDS, along with a detailed account in the resident's medical records of their ability and any assistance required. Include notes on any safety considerations or adaptations used.

6. Common Errors to Avoid

   • Not considering the full scope of assistance needed, including setup and supervision.
   • Failing to document the task attempt or the reason for not attempting it due to medical or safety concerns.
   • Overlooking the resident's improvement or decline in ability since admission.

7. Practical Application

   • Example: At discharge, Ms. Lee can maneuver her wheelchair independently over a 50-foot distance and around two turns without physical help but benefits from verbal reminders to slow down at turns for safety. The correct code is 04 (Supervision or touching assistance).

The Step-by-Step Coding Guide for item GG0170R3 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.