Step-by-Step Coding Guide for Item Set GG0130B3: Oral Hygiene (Discharge Performance)

This guide will help ensure accurate coding and documentation of a resident's discharge performance in oral hygiene, as specified in item GG0130B3 of the MDS 3.0.

1. Review of Medical Records

• Objective: Determine the resident's ability to manage oral hygiene at discharge.
• Key Points:
  • Review medical records for dental assessments, nursing notes, occupational therapy evaluations, and care plans documenting the resident’s oral hygiene abilities close to discharge.
  • Look for mentions of improvements, regressions, or consistency in the resident’s ability to brush teeth, use mouthwash, or manage dentures independently or with assistance.

2. Understanding Definitions

• Objective: Define "Oral Hygiene" in the context of discharge performance.
• Key Points:
  • Oral Hygiene: Involves the resident's capacity to clean their teeth (or dentures) and mouth, encompassing brushing, mouthwash use, and denture care.

3. Coding Instructions

• Objective: Document the resident's discharge performance in oral hygiene accurately.
• Key Points:
  • Use the standardized 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 resident did not perform the activity, code as 8 (activity not occurred).

4. Coding Tips

• Assess the resident’s most dependent level of performance in oral hygiene tasks during the discharge assessment period.
• Consider any use of adaptive devices or modifications to the resident's routine that were implemented during their stay.

5. Documentation

• Objective: Ensure comprehensive documentation of the resident's oral hygiene performance at discharge.
• Key Points:
  • Record detailed observations about the resident’s discharge performance in oral hygiene, including the use of any adaptive equipment and the level of assistance required.
  • Note changes in the resident’s oral hygiene ability since admission and any interventions that contributed to these changes.

6. Common Errors to Avoid

• Misinterpreting the need for occasional assistance as full independence.
• Failing to document changes in oral hygiene abilities or interventions that occurred during the resident's stay.

7. Practical Application

• Scenario: Mrs. Helen Garcia received occupational therapy during her stay to improve her manual dexterity affected by arthritis. At discharge, she demonstrates the ability to brush her teeth independently using an adapted toothbrush. Although she can apply toothpaste and brush without physical help, staff occasionally need to remind her of the importance of thorough oral care. Therefore, the MDS Coordinator codes her oral hygiene performance as 4, reflecting the need for supervision or touching assistance.

The Step-by-Step Coding Guide for item GG0130B3 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.