Step-by-Step Coding Guide for Item Set: GG0170S3. Wheel 150 Feet (Discharge Performance)

1. Review of Medical Records

   • Begin by reviewing the resident's medical and therapy records with a focus on mobility assessments and progress notes related to wheelchair use. Look for any documented changes in the resident's ability to self-propel in a wheelchair over a distance of 150 feet since admission. Pay special attention to physical therapy progress notes and care plans that document interventions aimed at improving or maintaining mobility.

2. Understanding Definitions

   • Wheel 150 Feet: Evaluates the resident's ability to independently maneuver a wheelchair over a distance of 150 feet. This distance tests not only the resident's physical capability but also endurance and maneuverability within the wheelchair.
   • Discharge Performance: Reflects the resident's level of ability to wheel 150 feet at the time of discharge from the facility, indicating progress or changes in mobility status since admission.

3. Coding Instructions

   • Assess the resident's performance by direct observation or reliable reports from caregiving staff. Use the following scale to accurately code the resident's ability:
     • 06: Independent - The resident completes the activity without any assistance.
     • 05: Setup or clean-up assistance - The resident requires assistance only before or after the task.
     • 04: Supervision or touching assistance - The resident needs verbal cues or light touch support.
     • 03: Partial/moderate assistance - The staff provides less than half the effort required.
     • 02: Substantial/maximal assistance - The staff provides more than half the effort required.
     • 01: Dependent - The resident requires full assistance to complete the activity.
     • 88: Not attempted due to medical condition or safety concerns.

4. Coding Tips

   • Accurately determine the level of independence by observing the resident's ability to complete the task. Consider the resident's need for rest stops, the ease of initiating and maintaining movement, and the ability to navigate the wheelchair effectively.

5. Documentation

   • Clearly document the coding decision in the MDS and provide detailed notes in the resident's medical record. Describe the observed performance, noting any assistance required or challenges faced during the task.

6. Common Errors to Avoid

   • Misjudging the resident's level of assistance needed, especially overlooking the need for supervision or verbal cues.
   • Failing to document the reason for not attempting the task, if applicable.

7. Practical Application

   • Example: At discharge, Mr. Hernandez can self-propel in his manual wheelchair over 150 feet. He requires one brief rest stop due to fatigue but does not need physical assistance or verbal encouragement. The appropriate code is 06 (Independent), with notes detailing the brief rest stop and his overall endurance improvement since admission.

The Step-by-Step Coding Guide for item GG0170S3 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.