Name of the Procedure:

Self Care Functional Limitation, Discharge Status (G8989)

Summary

Self Care Functional Limitation, Discharge Status (G8989) is a code used to document a patient's self-care abilities at the time of discharge from therapy or when ending reporting. It helps healthcare providers assess the patient's ability to perform daily self-care activities without assistance.

Purpose

This procedure addresses the functional limitations related to self-care that a patient may have due to medical conditions such as stroke, surgery recovery, or chronic illness. The goal is to evaluate the patient's progress and any remaining limitations in self-care tasks, ensuring they can manage essential daily activities independently or with minimal help upon discharge.

Indications

• Patients recovering from surgery or major medical events
• Individuals with chronic illnesses affecting daily self-care abilities
• Patients undergoing physical or occupational therapy
• Individuals being discharged from rehabilitation services

Preparation

• No special preparation is required from the patient.
• Clinicians may review the patient's medical history and previous functional assessments.

Procedure Description

1. The healthcare provider conducts a comprehensive evaluation of the patient's ability to perform self-care tasks such as bathing, dressing, grooming, and eating.
2. Specific assessment tools and checklists may be used to gauge capability.
3. The provider will document the level of assistance required for each self-care task.
4. The G8989 code is then used to record the patient's discharge status concerning their self-care functional limitations in the medical record.

Duration

The assessment and documentation typically take 30 to 60 minutes.

Setting

Performed in various settings such as hospitals, outpatient clinics, rehabilitation centers, or home health care environments.

Personnel

• Physical therapists
• Occupational therapists
• Nurses
• Physicians or other qualified healthcare providers

Risks and Complications

There are no direct risks or complications associated with the assessment itself. The primary concern is ensuring accurate evaluation to prevent underestimating the patient's needs.

Benefits

• Provides a clear understanding of the patient's ability to manage self-care independently.
• Helps in planning appropriate discharge resources or continued care.
• Facilitates better communication among healthcare providers regarding the patient's status.

Recovery

• No recovery time is needed from the assessment itself.
• If limitations are identified, follow-up care or therapy may be recommended.

Alternatives

• Functional Independence Measure (FIM) assessments.
• Activities of Daily Living (ADL) scales.
• These alternatives also evaluate functional capabilities but might have different formats or scoring systems.

Patient Experience

• The patient may perform various self-care tasks during the evaluation.
• Comfort measures and support will be provided as needed.
• Any discomfort or difficulty experienced by the patient during the tasks will be noted and addressed.