Step-by-Step Coding Guide for Item Set GG0100A: Self-Care: Prior Function

This guide provides detailed instructions for accurately coding and documenting a resident's prior functioning in self-care activities, as specified in item GG0100A of the MDS 3.0.

1. Review of Medical Records

• Objective: Gather information on the resident's self-care abilities before the current illness, exacerbation, or injury.
• Key Points:
  • Review medical records, including physician notes, therapy assessments, and nursing documentation, for descriptions of the resident’s self-care abilities prior to admission.
  • Look for specific mentions of activities such as eating, dressing, bathing, and toileting.

2. Understanding Definitions

• Objective: Clarify the concept of "Prior Function in Self-Care."
• Key Points:
  • Prior Function: Refers to the resident's ability to perform self-care tasks before the onset of the current illness, exacerbation, or injury leading to the current stay.

3. Coding Instructions

• Objective: Guide on how to accurately code the resident's prior self-care function.
• Key Points:
  • Code the resident’s self-care abilities based on the information gathered, using the following scale:
    • 3: Independent
    • 2: Needed some help
    • 1: Dependent
  • If the information is not available, code as 8 (unknown).

4. Coding Tips

• When possible, corroborate reported prior self-care abilities with family members, caregivers, or through reviewing previous care documentation to ensure accuracy.
• Be mindful that a resident's self-reported abilities may differ from observed or documented abilities due to recall bias or changes in health status.

5. Documentation

• Objective: Maintain thorough documentation supporting the coding of prior self-care function.
• Key Points:
  • Document the sources of information used to determine the resident’s prior function in self-care, including dates and details of the documentation reviewed.
  • Note any discrepancies between reported and observed abilities and the rationale for the final coding decision.

6. Common Errors to Avoid

• Failing to review a comprehensive range of sources when determining prior self-care abilities, leading to inaccurate coding.
• Assuming a level of function without evidence from the resident's medical history or family/caregiver reports.

7. Practical Application

• Scenario: Mr. John Smith was admitted to the facility following a stroke. His daughter reports that prior to his stroke, Mr. Smith was able to dress himself, bathe with minimal assistance, and eat independently. The therapy assessment conducted two months before his stroke confirms these abilities. Based on this information, the MDS Coordinator codes Mr. Smith’s prior self-care abilities for eating as 3 (independent), dressing as 3 (independent), and bathing as 2 (needed some help).

The Step-by-Step Coding Guide for item GG0100A 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.