Step-by-Step Coding Guide for Item Set GG0130E3: Chair/Bed-to-Chair Transfer (Discharge Performance)

This guide is designed to accurately code and document a resident's discharge performance in chair/bed-to-chair transfers, as specified in item GG0130E3 of the MDS 3.0.

1. Review of Medical Records

• Objective: Ascertain the resident's ability to transfer from a bed to a chair and back at discharge.
• Key Points:
  • Review the resident's medical records, focusing on recent nursing assessments, physical and occupational therapy evaluations, and care plans for descriptions of transfer abilities at discharge.
  • Pay attention to notes regarding the use of assistive devices or the need for human assistance during transfers close to the discharge date.

2. Understanding Definitions

• Objective: Define "Chair/Bed-to-Chair Transfer."
• Key Points:
  • Chair/Bed-to-Chair Transfer: Involves safely moving from a lying position in bed to sitting in a chair or wheelchair, and vice versa. This includes the ability to sit up, stand (if applicable), and sit down, with or without assistance.

3. Coding Instructions

• Objective: Document the resident's discharge performance in transferring accurately.
• Key Points:
  • Use 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

• Assess the resident’s transfer performance based on the most dependent episode of chair/bed-to-chair transfer observed near discharge.
• Consider the entire discharge assessment period for a comprehensive view of the resident's abilities.

5. Documentation

• Objective: Ensure thorough documentation of the resident's discharge performance.
• Key Points:
  • Document observations of the resident's transfer process, noting any required assistance and the use of equipment or devices.
  • Include any improvements or declines in the resident's ability to transfer, as observed during their stay.

6. Common Errors to Avoid

• Coding a resident as independent without considering occasional needs for setup or supervision.
• Neglecting to document the resident's progress or regression in transfer abilities throughout their stay.

7. Practical Application

• Scenario: Mrs. Susan Thompson, who underwent knee surgery, showed significant improvement in her mobility during her stay. By discharge, she was able to transfer from bed to chair with minimal assistance, primarily needing help to ensure balance while standing. Given this improvement, the MDS Coordinator codes her transfer performance as 3 (partial/moderate assistance) in GG0130E3.

The Step-by-Step Coding Guide for item GG0130E3 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.