Step-by-Step Coding Guide for Item Set GG0130B5: Oral Hygiene (OBRA/Interim Performance)

This guide will assist in accurately coding and documenting a resident's performance in oral hygiene during an OBRA or interim performance assessment, as specified in item GG0130B5 of the MDS 3.0.

1. Review of Medical Records

• Objective: Ascertain the resident's oral hygiene abilities during the OBRA or interim assessment period.
• Key Points:
  • Examine nursing assessments, dental consultations, and occupational or physical therapy evaluations that describe the resident's oral hygiene practices.
  • Look for documentation on the resident's ability to brush teeth, use mouthwash, and care for dentures independently or with assistance.

2. Understanding Definitions

• Objective: Define "Oral Hygiene" in the context of OBRA/Interim Performance.
• Key Points:
  • Oral Hygiene: Involves cleaning the mouth, teeth, and dentures (if applicable) to maintain mouth cleanliness and health. This includes brushing teeth, using mouthwash, and managing dentures.

3. Coding Instructions

• Objective: Document the resident's OBRA/interim performance in oral hygiene accurately.
• Key Points:
  • Utilize the following scale to code oral hygiene performance:
    • 6: Independent
    • 5: Setup or clean-up assistance
    • 4: Supervision or touching assistance
    • 3: Partial/moderate assistance
    • 2: Substantial/maximal assistance
    • 1: Dependent
  • If the activity did not occur, code as 8 (activity not occurred).

4. Coding Tips

• Base the coding on the resident’s performance over the interim assessment period.
• Consult with interdisciplinary team members, including nursing staff and therapists, for comprehensive insight into the resident's abilities and needs.

5. Documentation

• Objective: Ensure comprehensive documentation of the resident's oral hygiene performance.
• Key Points:
  • Record detailed observations of the resident's oral hygiene routines, including the need for assistance and the use of adaptive equipment.
  • Include any relevant health conditions that affect oral hygiene practices in the care plan notes.

6. Common Errors to Avoid

• Coding a resident as independent without considering the occasional need for setup, clean-up, or supervision.
• Failing to document changes in oral hygiene ability during the assessment period.

7. Practical Application

• Scenario: Mr. Alberto Garcia, during his OBRA assessment period, demonstrates the ability to brush his teeth and use mouthwash without assistance but struggles to manage his dentures independently. After observing Mr. Garcia and consulting with the care team, it's noted that while he independently maintains his natural teeth's hygiene, he requires partial assistance to insert and remove his dentures. The MDS Coordinator codes his oral hygiene performance as 3 (partial/moderate assistance) in GG0130B5.

The Step-by-Step Coding Guide for item GG0130B5 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.