GG0130H5: Putting on/taking off footwear (OBRA/Interim Performance), Step-by-Step

Step-by-Step Coding Guide for Item Set GG0130H5: Putting on/Taking off Footwear (OBRA/Interim Performance)

1. Review of Medical Records

• Objective: To determine the resident's ability to put on and take off footwear.
• Process:
  • Occupational Therapy Notes: Review occupational therapy assessments that evaluate the resident's ability to manage footwear.
  • Nursing Notes: Examine daily nursing notes for documented assistance provided during dressing.
  • Care Plans: Look at care plans for specific instructions or goals related to footwear management.
  • Resident Interviews: If possible, interview the resident about their ability to manage footwear independently.

2. Understanding Definitions

• Putting on/Taking off Footwear: This task involves the resident’s ability to put on and remove socks, shoes, and other footwear, including managing any fasteners such as laces, buckles, or Velcro straps.

3. Coding Instructions

• Code GG0130H5:
  • 06: Independent - Resident completes the activity with no assistance.
  • 05: Setup or clean-up assistance - Resident completes the activity, but another person sets up or cleans up.
  • 04: Supervision or touching assistance - Resident completes the activity with verbal cues or light touch.
  • 03: Partial/moderate assistance - Helper does less than half of the effort.
  • 02: Substantial/maximal assistance - Helper does more than half of the effort.
  • 01: Dependent - Helper does all of the effort.
• Example: If a resident can put on and take off their shoes but needs help tying shoelaces, code GG0130H5 as '03'.

4. Coding Tips

• Observation: Directly observe the resident performing the task to ensure accurate coding.
• Consistency: Ensure coding reflects the resident’s usual performance, not just occasional or exceptional instances.

5. Documentation

• Required Documentation:
  • Assessment Records: Detailed notes from occupational therapy and nursing staff documenting the resident’s ability and the level of assistance required.
  • Care Plan Entries: Specific goals and interventions related to footwear management.
• Example: "On 05/10/2024, during morning care, the resident required moderate assistance to put on shoes and socks, needing help with aligning and fastening Velcro straps."

6. Common Errors to Avoid

• Inconsistent Reporting: Avoid discrepancies between different staff reports and observations.
• Ignoring Adaptive Devices: Ensure the use of adaptive devices is documented and considered in the assessment.
• Overlooking Variability: Consider variations in the resident’s ability based on time of day, fatigue, or health status.

7. Practical Application

• Scenario: A resident with limited mobility due to arthritis can put on socks independently but needs help to put on and fasten shoes. During an occupational therapy session, the therapist documents the resident’s need for assistance with shoes. The care plan includes goals for improving independence in dressing. Based on these consistent observations, GG0130H5 is coded as '03'.

Please note that the information provided in this guide for MDS 3.0 Item set GG0130H5 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.