Step-by-Step Coding Guide for Item Set GG0130F3: Toilet Transfer (Discharge Performance)

This guide provides a systematic approach to accurately code and document a resident's discharge performance in toilet transfers, as specified in item GG0130F3 of the MDS 3.0.

1. Review of Medical Records

• Objective: Ascertain the resident's ability to transfer to and from the toilet at discharge.
• Key Points:
  • Thoroughly review the resident’s medical history, focusing on physical and occupational therapy evaluations, nursing assessments, and care plans related to the resident’s ability to transfer to and from the toilet.
  • Look for progress notes indicating improvements or declines in the resident's transfer abilities throughout their stay.

2. Understanding Definitions

• Objective: Clarify "Toilet Transfer."
• Key Points:
  • Toilet Transfer: Involves the action of moving to and from the toilet, which includes standing up from a seated position, moving from a wheelchair or other device to the toilet, and vice versa. This may involve the use of assistive devices or require assistance from others.

3. Coding Instructions

• Objective: Document the resident's discharge performance in toilet transfers accurately.
• Key Points:
  • Utilize the standard scale to code toilet 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 was not attempted during the assessment period.

4. Coding Tips

• Base the coding on the resident’s most dependent episode of toilet transfer near the discharge date.
• Ensure that any use of assistive devices is considered when determining the level of independence.

5. Documentation

• Objective: Ensure comprehensive documentation of the resident's discharge performance in toilet transfers.
• Key Points:
  • Record observations about the resident's process of transferring to and from the toilet, including any assistance required and the use of equipment or modifications.
  • Document the resident's progress in transfer abilities, interventions used to enhance these abilities, and any remaining challenges at discharge.

6. Common Errors to Avoid

• Failing to capture improvements in the resident’s ability to transfer to and from the toilet because of not reviewing the most current assessments.
• Misinterpreting the use of grab bars or raised toilet seats as full dependence without considering the resident's actual need for human assistance.

7. Practical Application

• Scenario: Ms. Linda Carter, admitted with limited mobility due to knee surgery, showed significant improvement in her ability to transfer to and from the toilet during her stay. By discharge, she required only a grab bar for stabilization but no human assistance, indicating a level of independence not present at admission. Thus, she is coded as 6 (independent) in GG0130F3, reflecting her ability to perform toilet transfers independently by the time of discharge.

The Step-by-Step Coding Guide for item GG0130F3 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.