Step-by-Step Coding Guide for Item Set GG0130A3: Eating (Discharge Performance)

This guide is designed to ensure accurate coding and documentation of a resident's discharge performance in eating, as specified in item GG0130A3 of the MDS 3.0.

1. Review of Medical Records

• Objective: Ascertain the resident's ability to eat at discharge.
• Key Points:
  • Review medical records focusing on dietary consultations, occupational therapy evaluations, and nursing assessments that describe the resident’s eating abilities at discharge.
  • Look for progress notes and care plans documenting changes in the resident's eating ability throughout their stay.

2. Understanding Definitions

• Objective: Clarify "Eating" in the context of discharge performance.
• Key Points:
  • Eating: Refers to the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow it. This includes managing a modified diet if necessary and using adaptive equipment.

3. Coding Instructions

• Objective: Document the resident's discharge performance in eating accurately.
• Key Points:
  • Utilize the following scale to code discharge performance in eating:
    • 6: Independent
    • 5: Setup or clean-up assistance
    • 4: Supervision or touching assistance
    • 3: Partial/moderate assistance
    • 2: Substantial/maximal assistance
    • 1: Dependent
  • If the resident did not eat during the assessment period, code as 88 (not attempted).

4. Coding Tips

• Base the coding on the resident’s eating performance closest to discharge, considering their most dependent episode.
• If the resident’s eating ability varied near discharge, document the rationale for the chosen code reflecting their typical level of performance.

5. Documentation

• Objective: Ensure comprehensive documentation of the resident's eating performance at discharge.
• Key Points:
  • Record observations regarding the resident's use of utensils, need for assistance, and any difficulties encountered with eating.
  • Include information on adaptive devices or diet modifications used to support the resident's eating independence.

6. Common Errors to Avoid

• Assuming no change in eating performance from admission to discharge without confirming through recent assessments.
• Misinterpreting occasional assistance for setup or supervision as full independence.

7. Practical Application

• Scenario: Mr. James Doe, who was admitted with significant swallowing difficulties, received targeted therapy to improve his eating abilities. At discharge, he can eat independently but requires his meals to be served in a specific, easy-to-swallow consistency. Based on his need for a modified diet but no physical assistance, the MDS Coordinator codes him as 6 in GG0130A3, reflecting his achieved independence in eating with accommodations for diet consistency.

The Step-by-Step Coding Guide for item GG0130A3 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.