Harmony Healthcare Blog

Investigating ADL Coding

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Mon, Jul 25, 2011
Kris Mastrangelo, OTR/L, LNHA, MBA
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Harmony continually discusses the significant clinical impact of accurate documentation. Accuracy is vital in developing the care plan, identifying changes in condition and attaining reimbursement that the SNF is entitled for services provided. The RAI Users Manual encourages the assessor to "engage direct care staff, from all shifts, which have cared for the resident over the past 7 days in discussions regarding the resident's ADL functional performance. Ask probing questions beginning with the general and proceeding to the more specific." It is with these discussions that inconsistencies can be identified, clarified and corrected. RUG's measure the resources utilized to provide care to the residents.


Harmony stresses the importance of breaking each ADL task into sub-tasks when making coding decisions entered onto the MDS. Once physical contact (touch) has been made with the resident, physical assist has been provided. The level of physical assist must then be determined.


CNA and Nursing staff are asked to consider the following:

 1.   Bed Mobility:  

  • How does the resident position in bed or move from lying to sitting/sitting to lying?
  • Was the resident boosted up while in bed, regardless of independence in turning side to side?
  • Does staff lift the resident's legs to assist in getting in or out of the bed?
  •  How many people provided this assist, even once during the entire shift?

2. Transfers:

  •  Did staff place hands on the resident during any transfers to either provide contact guard to steady or use a gait belt to assist in rising? 
  • How many people provided this assist, even once during the entire shift?

 3.   Eating:

  • Was the resident provided with any hands on assist (touch) to consume food or take fluids?
  • Was the resident dependent for any part of a meal, i.e., to finish the meal due to fatigue or cognitive barriers?
  • Was the resident assisted with intake of any type throughout the course of the shift?
  • How does the resident take fluids during the night shift or while in bed?
  •  Is the resident assisted with nourishments?

4.   Toileting/Incontinence Care:

  • Was the resident toileted or provided incontinence care during the entire shift?
  •  How does the resident complete thorough hygiene, clothing management, donn a brief, or transfer on and off of the toilet, bed pan or commode?
  • Does the patient have a catheter or ostomy? Who provided the care?
  • For the resident incontinent while in bed, how many assists are provided to manage incontinence care, linen changes hygiene?
  • Is the resident resistive with incontinence care? If so, how many staff members did it take to complete the task, regardless of the resident's usual capabilities?

5.   Cognitively Impaired Residents:

  • Was assistance provided with any ADL tasks such as physical assist or tactile cues with transfers, bed mobility, eating or toileting? An example includes lifting the residents hand to place at the edge of the bed in order to rise or lifting the resident's foot off the wheel chair pedal in order to transfer. Both are examples of extensive assistance.
  • Does the resident require any hands on assistance to start a task due to difficulty with attention, task segmentation or inability to follow verbal cues? An example includes lifting the resident's hand with a cup in it towards the mouth in order to initiate the task of drinking. This is an example of extensive assist even if the patient completes the meal independently after getting started.  

6.   Fall Risks/Personal Alarms:

  • Why does the patient require a personal alarm? In general, an alarm is used to prevent unassisted or unsupervised ambulation, transfers, toileting or getting out of bed.
  •  If so, when responding to the alarm was physical (touch) assistance provided?
  •  What degree of assist was provided?

The coding of ADL's is intended to be a measurement of actual self-performance and actual staff support. Do not code for what the resident is identified as capable of doing, code for what actually occurred. Variations in function are an expected occurrence as residents demonstrate changes day to day and shift to shift due to a variety of medical and psychological reasons.


The coding of more assistance provided from one CNA to another is not a reflection of staff's inability to perform their job effectively. On the contrary, residents that require assist in moving towards the top of the bed benefit from the 2 person lift to preserve skin integrity and prevent injury to both residents and staff. The 2 person assist is just good care.


CNA and Nursing staff documentation is encouraged to reflect the most support provided over the entire 8 hour shift. A patient that is capable of increased participation, yet receives greater assist warrants a more in-depth assessment as to the causes of such variances. Accurate ADL coding will assist in identifying and resolving these issues.


A number of factors impact ADL status:


  • Fatigue.
  • Weakness.
  • Acute illnesses.
  • Exacerbation of chronic illnesses.
  • Cognitive deficits.
  • Medication effects.
  • Behaviors such as resistance with care or agitation.
  • Pain.
  • Lack of motivation.
  • Falls.

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Topics: ADL

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