Section J Health Conditions – Unsteady Gait.
Question: How do I code this item when the person uses a walking device such as a stick or walking frame?
Answer: An uneven gait may or may not be improved by using a walking device. The person may also have episodes of walking unaided (e.g., they may furniture walk inside their home or from chair to walking device), during the 3-day observation period. Check the definition and examples of an unsteady gait in the coding manual then assess the presence of an unsteady gait by observing the person walk. If observation is not possible, record what is reported by the person/carers/family/whānau to code this item.
Disease Diagnoses – Coding option 3. Diagnosis present, monitored, but no active treatment.
Question: What is a good example of: 3. Diagnosis present, monitored but no active treatment.
Answer: Examples include such things as:
- the person who has a diagnosis of Hypertension with no medication but is on daily BP monitoring to determine whether medication will be required.
- the continued testing of urine and observing for symptoms after treatment of a Urinary Tract Infection (UTI), to monitor for re-infection.
- Neurological observations after an unintended knock to the head.
Section M Activities Pursuit – M1. Average Time Involved in Activities.
Question: How do I code this item if the amount of time varies over the 3-day look back period?
Answer: If the amount of time the person spent engaged in activities varies across the 3-day look back period, review the time spent each day and document the average for the 3 days.
Section E6 - Urgency of Services
Question: How should I code Urgency of Services when the person already has services in place?
Answer: When a person already has services in place, (e.g., home help) and the current assessment demonstrates a continued need for these services, code these services as required. Code the time option that reflects the continued need most accurately.
For instance, if home help is delivered weekly, code ‘1. 48 hours or more’.
This links the current assessment outcomes to the care plan.