GG0130F5: Upper Body Dressing (OBRA/Interim Performance), Step-by-Step

Step-by-Step Coding Guide for Item Set GG0130F5: Upper Body Dressing (OBRA/Interim Performance)

1. Review of Medical Records

• Objective: To assess the resident's ability to dress the upper body, including managing shirts, bras, and other upper body garments.
• Process:
  • Review occupational therapy assessments and nursing notes that document the resident’s ability and technique in dressing.
  • Examine care plan updates and therapy session notes for any interventions or progress in upper body dressing skills.
  • Consult with caregiving staff who assist the resident with daily activities, focusing on dressing routines.

2. Understanding Definitions

• Upper Body Dressing: This involves tasks related to putting on and taking off clothing that covers the upper body, including managing fasteners, aligning clothing appropriately, and handling different types of garments.

3. Coding Instructions

• Code GG0130F5:
  • 06: Independent - Resident completes the task by themselves without any assistance.
  • 05: Setup or clean-up assistance - Resident completes the task but requires setup or cleaning afterward.
  • 04: Supervision or touching assistance - Resident requires verbal cues or minor physical help.
  • 03: Partial/moderate assistance - Resident does more than half of the effort.
  • 02: Substantial/maximal assistance - Resident does less than half of the effort.
  • 01: Dependent - Helper does all of the task, resident does none of the effort.
• Example: If a resident needs help with fastening buttons and aligning a shirt but does most of the task themselves, code GG0130F5 as '03'.

4. Coding Tips

• Observe the resident over multiple instances to ensure a consistent and accurate assessment of their abilities.
• Pay attention to the use of adaptive devices or modifications that might affect the resident’s independence level.

5. Documentation

• Required Documentation:
  • Detailed descriptions of the resident's ability to manage upper body dressing, including types of assistance required.
  • Notes from occupational therapists or nurses that specify any adaptive techniques or aids used by the resident.
  • Care plan entries that reflect current goals and interventions related to dressing.
• Documentation should be clear and comprehensive, reflecting an accurate depiction of the resident’s abilities and needs.

6. Common Errors to Avoid

• Failing to note the use of adaptive equipment which can impact the level of assistance needed.
• Overlooking changes in the resident’s ability that might occur due to health fluctuations.
• Inconsistency in documentation across different shifts or care providers, leading to inaccurate coding.

7. Practical Application

• Scenario: A resident recovering from a shoulder surgery has limited range of motion, affecting their ability to dress their upper body. During an assessment, the occupational therapist notes that the resident struggles with shirts, particularly with fastening buttons and pulling a shirt over the head. The therapist works with the resident to use modified clothing and documents the assistance needed during dressing. The resident requires help to position the shirt and secure fasteners but manages to pull the shirt down mostly independently. For MDS coding, based on detailed documentation and observed assessments, GG0130F5 is coded as '03' to accurately reflect the resident's level of dependence.

Please note that the information provided in this guide for MDS 3.0 Item setGG0130F5 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.