Step-by-Step Coding Guide for Item Set GG0130E1: Chair/Bed-to-Chair Transfer (Admission Performance)

This guide provides a comprehensive approach to accurately code and document a resident's admission performance in chair/bed-to-chair transfers, as outlined in item GG0130E1 of the MDS 3.0.

1. Review of Medical Records

• Objective: Determine the resident's ability to transfer from a bed to a chair and back upon admission.
• Key Points:
  • Thoroughly review the resident’s medical records, including nursing assessments, physical and occupational therapy evaluations, and physician notes for information on the resident’s transfer abilities upon admission.
  • Pay special attention to documentation on the use of assistive devices or the need for human assistance during transfers.

2. Understanding Definitions

• Objective: Clarify the activity involved in "Chair/Bed-to-Chair Transfer."
• Key Points:
  • Chair/Bed-to-Chair Transfer: Involves the ability to safely move from a lying position in bed to sitting in a chair or wheelchair, and vice versa. This includes sitting up from lying down, standing up (if applicable), and sitting down into the chair or wheelchair.

3. Coding Instructions

• Objective: Accurately code the resident's admission performance in transferring.
• Key Points:
  • Utilize the following scale to code transfer performance:
    • 6: Independent
    • 5: Setup or clean-up assistance
    • 4: Supervision or touching assistance
    • 3: Partial/moderate assistance
    • 2: Substantial/maximal assistance
    • 1: Dependent
  • Code 88 if the activity did not occur during the assessment period.

4. Coding Tips

• Base the coding on the resident’s most dependent episode of chair/bed-to-chair transfer during the first three days of the current SNF stay.
• Assess whether the resident's use of assistive devices still allows them to complete the transfer independently.

5. Documentation

• Objective: Maintain comprehensive documentation of the resident's transfer abilities.
• Key Points:
  • Record detailed observations of the resident’s transfer process, including any assistance needed and the use of equipment or devices.
  • Document specific conditions or impairments affecting the resident's ability to perform transfers and any interventions planned or provided.

6. Common Errors to Avoid

• Incorrectly coding a resident as independent without considering occasional needs for setup or supervision.
• Overlooking changes in the resident’s ability to transfer during the assessment period.

7. Practical Application

• Scenario: Mr. Henry Lee was admitted to the facility following a hip replacement surgery. Upon admission, he required substantial assistance from two staff members to safely transfer from bed to chair due to pain and limited weight-bearing status. Based on this assessment, the MDS Coordinator codes his chair/bed-to-chair transfer performance as 2 (substantial/maximal assistance) in GG0130E1.

The Step-by-Step Coding Guide for item GG0130E1 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.