Step-by-Step Coding Guide for Item Set GG0130A1: Eating (Admission Performance)

This guide provides detailed instructions for accurately coding and documenting a resident's admission performance in eating, as specified in item GG0130A1 of the MDS 3.0.

1. Review of Medical Records

• Objective: Determine the resident's ability to eat upon admission.
• Key Points:
  • Examine medical records for notes from nursing assessments, dietary consultations, and occupational therapy evaluations that describe the resident’s eating abilities upon admission.
  • Pay attention to descriptions of the resident's ability to use utensils, make food choices, chew, and swallow.

2. Understanding Definitions

• Objective: Clarify the activity of "Eating."
• Key Points:
  • Eating: Involves the ability to use suitable utensils to bring food (and/or liquid) to the mouth and swallow food (and/or liquid) once the meal is presented on a table/tray. Includes modified food consistency.

3. Coding Instructions

• Objective: Accurately code the resident's admission performance in eating.
• Key Points:
  • Use the following scale to code eating performance:
    • 6: Independent
    • 5: Setup or clean-up assistance
    • 4: Supervision or touching assistance
    • 3: Partial/moderate assistance
    • 2: Substantial/maximal assistance
    • 1: Dependent
  • Code 8 if activity not occurred.

4. Coding Tips

• Assess the resident's eating ability based on the most dependent episode of eating during the 3-day assessment period.
• Observe the resident during multiple meals, if possible, to accurately assess their needs and abilities.

5. Documentation

• Objective: Maintain thorough documentation regarding the resident's eating performance.
• Key Points:
  • Document specific observations about the resident’s ability to eat, including the use of utensils, assistance needed, and any difficulties with chewing or swallowing.
  • Note any adaptive equipment or modified diet consistency required to facilitate eating.

6. Common Errors to Avoid

• Coding a resident as independent without considering occasional needs for setup, clean-up, or supervision.
• Overlooking changes in the resident's eating ability during the 3-day assessment period.

7. Practical Application

• Scenario: Upon admission, Mrs. Smith demonstrates the ability to eat independently but requires her food to be cut into smaller pieces before she can eat. During her first meal, staff observed that they needed to cut her meat but she managed all other aspects of the meal herself. Based on this, the MDS Coordinator codes her as 5 for GG0130A1, indicating she requires setup assistance.

The Step-by-Step Coding Guide for item GG0130A1 in MDS 3.0 Section GG is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.