Step-by-Step Coding Guide for Item Set GG0130I3: Personal Hygiene (Discharge Performance)

1. Review of Medical Records

• Objective: Ensure accurate and complete documentation of the resident's personal hygiene performance at discharge.
• Steps:
  1. Collect Medical Records: Gather the resident's medical records, care plans, progress notes, and previous assessments.
  2. Identify Relevant Information: Focus on notes and entries related to personal hygiene activities, such as washing face and hands, oral care, and grooming.
  3. Consult with Care Team: Engage with the interdisciplinary care team to verify the resident’s personal hygiene abilities at discharge.

2. Understanding Definitions

• Personal Hygiene: Refers to the activities involved in maintaining cleanliness and grooming, including washing face and hands, oral care, and hair care.
• Discharge Performance: Reflects the resident's ability to perform personal hygiene activities at the time of discharge from the facility.

3. Coding Instructions

• Steps:
  1. Assessment: Determine the resident’s ability to perform personal hygiene tasks based on direct observation, care team input, and medical records.
  2. Performance Scale: Use the 6-point performance scale to rate the resident’s ability:
     • 6: Independent
     • 5: Setup or clean-up assistance
     • 4: Supervision or touching assistance
     • 3: Partial/moderate assistance
     • 2: Substantial/maximal assistance
     • 1: Dependent
  3. Enter Code: Enter the appropriate code (1-6) in item set GG0130I3 to reflect the resident’s discharge performance.

4. Coding Tips

• Observation: Conduct thorough observations during routine care activities to accurately assess personal hygiene capabilities.
• Interdisciplinary Input: Collaborate with nursing staff, occupational therapists, and family members to gather comprehensive insights.
• Documentation Consistency: Ensure that the coding reflects consistent and accurate documentation across all medical records.

5. Documentation

• Required:
  • Progress Notes: Document observations and assessments related to personal hygiene activities.
  • Care Plans: Include goals and interventions related to improving or maintaining personal hygiene abilities.
  • Discharge Summary: Summarize the resident’s personal hygiene performance and any necessary follow-up care.

6. Common Errors to Avoid

• Incomplete Observations: Avoid coding based on incomplete or inconsistent observations.
• Inaccurate Ratings: Ensure the performance scale is used accurately, reflecting the resident’s actual abilities.
• Lack of Interdisciplinary Collaboration: Engage the full care team to avoid missing critical insights into the resident’s personal hygiene performance.

7. Practical Application

• Example:
  • Resident Profile: John Doe, an 82-year-old male with a history of stroke, being discharged from a rehabilitation facility.
  • Steps:
    1. Review Records: Collect John’s progress notes, care plans, and previous assessments focusing on personal hygiene.
    2. Assess Performance: Observe John during his morning routine, noting his ability to wash his face and hands, perform oral care, and groom his hair.
    3. Consult Care Team: Discuss John’s abilities with nursing staff and occupational therapists who have worked with him.
    4. Rate Performance: Based on observations and input, determine that John requires setup assistance (code 5).
    5. Enter Code: Document code 5 in item set GG0130I3 to reflect John’s discharge performance for personal hygiene.

Please note that the information provided in this guide for MDS 3.0 Item set GG0130I3 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.