GG0130H1: Putting on/Taking off Footwear (Admission Performance), Step-by-Step

Step-by-Step Coding Guide for GG0130H1: Putting on/Taking off Footwear (Admission Performance)

1. Review of Medical Records

Objective: Assess the resident’s ability to put on and take off footwear during the admission assessment period.

Actions:

• Review nursing notes, therapy records, and self-care assessments.
• Observe the resident putting on or taking off socks, shoes, or other footwear to determine their performance and assistance required.

2. Understanding Definitions

GG0130H1: Putting on/Taking off Footwear (Admission Performance): This item evaluates the resident’s ability to complete the task of putting on or taking off footwear independently or with the help of a caregiver. This includes socks, shoes, and orthotics if used.

Example Scenarios:

• Resident A uses an ankle-foot orthosis (AFO) and requires touching assistance from a caregiver to maintain balance while putting on footwear. This would be coded 04: Supervision or touching assistance​.

3. Coding Instructions

Step-by-Step:

• Step 1: Assess the resident’s ability to put on and take off footwear.
• Step 2: Determine the level of assistance required:
  • 06: Independent: The resident completes the activity without help.
  • 05: Setup or clean-up assistance: The resident performs the task, but a helper sets up or retrieves footwear.
  • 04: Supervision or touching assistance: The resident needs verbal cues or steadying assistance.
  • 03: Partial/moderate assistance: The resident requires some help, but provides more than half the effort.
  • 02: Substantial/maximal assistance: The helper provides more than half the effort.
  • 01: Dependent: The resident is fully dependent and needs two or more helpers​.

Illustration:

• Scenario: A resident with fine motor coordination issues requires help threading their socks onto their feet, and a caregiver straps their shoes. This should be coded as 02: Substantial/maximal assistance​.

4. Coding Tips

• Orthotics/Prosthetics Considered Footwear: If the resident uses devices like orthotics, they should be included as part of the footwear assessment​.
• Record Performance Over the First Three Days: Code based on the resident’s usual performance during the initial 3-day assessment window​.

5. Documentation

Objective: Ensure clear documentation of the resident’s ability and the assistance required for putting on and taking off footwear.

Actions:

• Record the type of assistance provided, including any devices used, such as orthotics or prosthetics.
• Document whether the resident needed assistance or completed the task independently during the assessment period.

6. Common Errors to Avoid

• Incorrectly Coding Setup Assistance: If a helper only sets up the footwear (e.g., places shoes within reach), this should be coded as 05: Setup or clean-up assistance​.
• Incomplete Documentation: Ensure that all elements of the task (putting on/taking off footwear) are fully documented in the resident’s medical record.

7. Practical Application

• Example 1: A resident puts on socks independently but needs help putting on their shoes. This would be coded as 03: Partial/moderate assistance.
• Example 2: A resident requires a caregiver to perform the entire task, including putting on both socks and shoes. This would be coded as 01: Dependent​.

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.