Step-by-Step Coding Guide for Item Set GG0130C1: Toileting Hygiene (Admission Performance)

This guide details how to accurately code and document a resident's admission performance in toileting hygiene, as outlined in item GG0130C1 of the MDS 3.0.

1. Review of Medical Records

• Objective: Determine the resident's ability to manage toileting hygiene upon admission.
• Key Points:
  • Examine the resident’s medical history, including nursing assessments, occupational therapy evaluations, and care plans for mentions of toileting hygiene abilities upon admission.
  • Look for notes regarding the resident's ability to maintain perineal hygiene, adjust clothing, and use the toilet or commode independently or with assistance.

2. Understanding Definitions

• Objective: Clarify "Toileting Hygiene."
• Key Points:
  • Toileting Hygiene: Involves managing clothing and wiping/ cleaning the body before and after using the toilet, commode, bedpan, or urinal. This includes maintaining perineal hygiene, adjusting clothes, and the ability to use toilet paper effectively.

3. Coding Instructions

• Objective: Accurately code the resident's admission performance in toileting hygiene.
• Key Points:
  • Use the following scale to code toileting 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
  • Code 8 if the activity did not occur during the assessment period.

4. Coding Tips

• Base coding on direct observations and consistent documentation during the first three days of the current SNF stay.
• Consider the resident’s most dependent episode of toileting hygiene during the assessment period for accurate coding.

5. Documentation

• Objective: Ensure comprehensive documentation supporting the coding of toileting hygiene.
• Key Points:
  • Document detailed observations of the resident’s toileting hygiene routines, including any assistance needed or the use of adaptive equipment.
  • Note any specific conditions or impairments that affect the resident’s ability to perform toileting hygiene independently.

6. Common Errors to Avoid

• Overlooking the need for setup or clean-up assistance as contributing to a resident’s level of independence.
• Failing to update coding based on changes in the resident’s toileting hygiene ability during the assessment period.

7. Practical Application

• Scenario: Upon admission, Mrs. Elizabeth Nguyen has arthritis, impacting her ability to manage toileting hygiene independently. She requires help with wiping and managing her clothing. During the initial assessment, occupational therapy notes her need for moderate assistance with these tasks. Based on this information, the MDS Coordinator codes her as 3 (partial/moderate assistance) in GG0130C1.

The Step-by-Step Coding Guide for item GG0130C1 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.