GG0130F1: Upper body dressing (Admission Performance), Step-by-Step

Step-by-Step Coding Guide for GG0130F1: Upper Body Dressing (Admission Performance)

1. Review of Medical Records

Objective: Assess the resident’s ability to dress their upper body during the admission assessment period.

Actions:

• Review the resident’s therapy notes, nursing documentation, and any relevant self-care assessments.
• Observe the resident or ask caregivers about their ability to put on and take off upper body clothing such as shirts, bras, sweaters, or nightgowns during the first three days of admission.

2. Understanding Definitions

GG0130F1: Upper Body Dressing: This item measures the resident’s ability to put on and remove clothing that covers the upper body. This includes items like shirts, bras, sweaters, and any prosthetic devices worn on the upper body.

Example Scenarios:

• Resident A: The resident can thread their arms through their shirt but requires help with fastening buttons. This would be coded as 03: Partial/moderate assistance, as the helper provides less than half of the effort required​.

3. Coding Instructions

Step-by-Step:

• Step 1: Assess the resident’s ability to put on and take off upper body clothing.
• Step 2: Determine the level of assistance required:
  • 06: Independent: The resident performs the activity without help.
  • 05: Setup or clean-up assistance: The resident dresses independently but needs a helper to set up clothing or equipment.
  • 04: Supervision or touching assistance: The helper provides only verbal cues or light touch.
  • 03: Partial/moderate assistance: The helper provides less than half of the effort.
  • 02: Substantial/maximal assistance: The helper provides more than half the effort.
  • 01: Dependent: The resident is fully dependent on a helper​.

Illustration:

• Scenario: Resident B can pull on their shirt but requires significant help to adjust and button it. This would be coded as 02: Substantial/maximal assistance​.

4. Coding Tips

• Assistive Devices: If the resident uses assistive devices or prosthetics (e.g., back braces), these are considered part of upper body dressing and should be included when determining the level of assistance required​.
• Usual Performance: Record the resident’s usual performance over the first three days of admission. Do not record their best or worst performance, but rather the typical level of independence they demonstrate​.

5. Documentation

Objective: Clearly document the resident’s upper body dressing performance, including any assistance needed and devices used.

Actions:

• Record the type of assistance required, such as buttoning or adjusting garments.
• Document any prosthetic devices or adaptive equipment involved in dressing.

6. Common Errors to Avoid

• Incorrectly Coding Setup Assistance: Ensure that if a helper only sets up or retrieves clothing, the activity is coded as 05: Setup or clean-up assistance.
• Incomplete Documentation: Ensure that all elements of the dressing process are thoroughly documented​.

7. Practical Application

• Example 1: A resident dresses independently but requires help with retrieving clothes from the closet. This should be coded as 05: Setup or clean-up assistance.
• Example 2: A resident needs help fastening a bra and adjusting their shirt. This would be coded as 03: Partial/moderate assistance​.

Please note that the information provided in this guide for MDS 3.0 Item set GG0130H1 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.