GG0170D3: Sit to Stand (Discharge Performance), Step-by-Step

Step-by-Step Coding Guide for Item Set GG0170D3: Sit to Stand (Discharge Performance)

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s ability to move from a sitting to a standing position at the time of discharge.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including physical therapy notes, nursing notes, care plans, and previous assessments.
  2. Identify Relevant Documentation: Look for documented instances of the resident’s ability to perform the sit-to-stand activity.
  3. Confirm Details: Verify the consistency of these observations through various sources within the medical records.

2. Understanding Definitions

• Sit to Stand: The ability of the resident to move from a sitting position to a standing position.
• Discharge Performance: The resident’s ability to perform this activity at the time of discharge from the facility.

3. Coding Instructions

• Steps:
  1. Observe the Activity: During the discharge assessment, observe the resident’s ability to move from a sitting to a standing position.
  2. Determine Level of Assistance: Identify the amount of assistance the resident requires to complete the activity.
  3. Code Appropriately: Use the following scale to code the resident’s performance:
     • Code 01: Dependent - Helper does all of the effort.
     • Code 02: Substantial/maximal assistance - Helper does more than half the effort.
     • Code 03: Partial/moderate assistance - Helper does less than half the effort.
     • Code 04: Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance.
     • Code 05: Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity.
     • Code 06: Independent - Resident completes the activity by themselves without assistance.

4. Coding Tips

• Accurate Observation: Ensure that the assessment is conducted in a consistent and controlled environment to accurately observe the resident’s abilities.
• Clarify Instructions: Make sure the resident understands the instructions for the activity.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the resident’s performance.

5. Documentation

• Required:
  • Observation Notes: Document the observations made during the assessment, including the level of assistance provided.
  • Therapy Reports: Include assessments from physical and occupational therapy sessions that detail the resident’s mobility and ability to perform the sit-to-stand activity.
  • Discharge Summary: Document the resident’s abilities and any assistance required at the time of discharge.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the resident’s ability through multiple observations.
• Incomplete Documentation: Make sure all relevant details about the resident’s sit-to-stand performance are thoroughly documented.
• Assumptions: Do not assume the resident’s abilities without proper documentation and observation.

7. Practical Application

• Example:
  • Resident Profile: John, an 85-year-old resident, is being assessed for his ability to move from a sitting to a standing position at the time of discharge.
  • Steps:
    1. Observe Performance: The nurse observes John as he moves from a sitting to a standing position.
    2. Identify Assistance Level: John requires moderate assistance to stand up from the chair.
    3. Document and Code: The nurse documents John’s performance as requiring partial/moderate assistance and codes GG0170D3 as "03".
  • Outcome: John’s ability to move from a sitting to a standing position is accurately documented and coded, ensuring proper follow-up and care planning.

Please note that the information provided in this guide for MDS 3.0 Item set GG0170D3 was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.