GG0130E1: Shower/bathe self (Admission Performance), Step-by-Step

Step-by-Step Coding Guide for Item Set GG0130E1: Shower/Bathe Self (Admission Performance)

1. Review of Medical Records

• Examine the resident’s medical records upon admission to assess their baseline level of independence and any noted limitations in performing activities of daily living (ADLs), specifically related to bathing.
• Look for notes from the admitting nurse, occupational therapist, or other healthcare providers regarding the resident’s ability to shower or bathe themselves.

2. Understanding Definitions

• Shower/Bathe Self: This refers to the resident’s ability to bathe themselves independently, including the tasks of soaping, rinsing, and drying the body, as well as getting in and out of the tub or shower safely.

3. Coding Instructions

• Code using a 6-point scale based on the resident’s admission performance:
  • 06 – Independent: Resident completes the activity by themselves without any type of assistance.
  • 05 – Setup or clean-up assistance: Resident completes the activity independently after someone sets up or cleans up.
  • 04 – Supervision or touching assistance: Resident requires verbal cues or touching/steadying assistance.
  • 03 – Partial/moderate assistance: Helper does less than half the effort.
  • 02 – Substantial/maximal assistance: Helper does more than half the effort.
  • 01 – Dependent: Helper does all of the effort.
  • 07 – Resident refused: The resident refused to participate in the bathing task.
  • 09 – Not applicable: The resident did not perform this activity prior to the current illness, exacerbation, or injury.
  • 88 – Not attempted due to medical condition or safety concerns: The activity was not attempted due to medical condition or safety concerns.

4. Coding Tips

• Observe the resident during their first few attempts at bathing to accurately assess their level of independence.
• Consult with the care team to gather multiple observations to ensure a consistent understanding of the resident’s abilities.

5. Documentation

• Document detailed descriptions of how the resident performs the bathing task, including any aids used (e.g., grab bars, bath chair), the type of assistance required, and reasons for assistance.
• Include notes on any environmental adaptations made or any safety concerns observed during the assessment.

6. Common Errors to Avoid

• Failing to differentiate between different types of assistance (e.g., setup assistance vs. physical support).
• Not updating the resident’s coding when there is a change in their ability to perform the activity due to health changes.

7. Practical Application

• Example: During the first week of admission, a resident requires a staff member to be present in the bathroom, providing steady assistance as they bathe. They manage to soap and rinse themselves but need help adjusting the shower head and stabilizing themselves while stepping out of the shower. This situation should be coded as 04 – Supervision or touching assistance.

Please note that the information provided in this guide for MDS 3.0 Item set GG0130E1 was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.