Step-by-Step Coding Guide for Item Set GG0130B1: Oral Hygiene (Admission Performance)

This guide provides comprehensive instructions for accurately coding and documenting a resident's admission performance in oral hygiene, as specified in item GG0130B1 of the MDS 3.0.

1. Review of Medical Records

• Objective: Determine the resident's ability to manage oral hygiene upon admission.
• Key Points:
  • Examine medical records for any dental assessments, nursing notes, or occupational therapy evaluations that describe the resident’s oral hygiene practices upon admission.
  • Look for mentions of the resident’s ability to brush teeth, use mouthwash, or denture care independently or with assistance.

2. Understanding Definitions

• Objective: Clarify "Oral Hygiene" in the context of admission performance.
• Key Points:
  • Oral Hygiene: Refers to the resident's ability to clean teeth (or dentures) and mouth, including brushing teeth, using mouthwash, and denture management.

3. Coding Instructions

• Objective: Accurately document the resident's admission performance in oral hygiene.
• Key Points:
  • Utilize the following scale to code oral hygiene performance:
    • 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 activity did not occur, code as 8 (activity not occurred).

4. Coding Tips

• Base the coding on the resident’s performance over the first three days of the current SNF stay.
• Consider the resident's need for adaptive devices or modifications to perform oral hygiene tasks.

5. Documentation

• Objective: Maintain detailed documentation of the resident's oral hygiene performance.
• Key Points:
  • Document observations related to the resident’s oral hygiene routines, including the need for assistance or use of adaptive equipment.
  • Include any relevant health conditions affecting oral hygiene practices, like arthritis or cognitive impairments, in the care plan notes.

6. Common Errors to Avoid

• Overlooking the need for setup or clean-up assistance as a form of independence.
• Failing to document oral hygiene practices accurately, leading to coding errors.

7. Practical Application

• Scenario: Upon admission, Mr. John Doe has Parkinson's disease, impacting his manual dexterity. During the initial assessment, it’s noted that while Mr. Doe attempts to brush his teeth independently, he struggles with toothpaste application and requires supervision to ensure thorough cleaning. Considering this, the MDS Coordinator codes his oral hygiene performance as 4, indicating the need for supervision or touching assistance.

The Step-by-Step Coding Guide for item GG0130B1 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.