Step-by-Step Coding Guide for Item Set GG0130C3: Toileting Hygiene (Discharge Performance)

This guide will assist in accurately coding and documenting a resident's discharge performance in toileting hygiene, as outlined in item GG0130C3 of the MDS 3.0.

1. Review of Medical Records

• Objective: Determine the resident's ability to manage toileting hygiene at discharge.
• Key Points:
  • Review the resident’s medical records, focusing on nursing assessments, occupational therapy evaluations, and care plans for descriptions of toileting hygiene abilities at discharge.
  • Look for notes on the resident’s ability to maintain perineal hygiene, manage clothing, and use toilet paper independently or with assistance close to the discharge date.

2. Understanding Definitions

• Objective: Clarify "Toileting Hygiene."
• Key Points:
  • Toileting Hygiene: Refers to the ability to effectively manage perineal hygiene, clothing adjustment before and after toileting, and the proper use of toilet paper. It encompasses activities performed in preparation for and completion of using the toilet, commode, bedpan, or urinal.

3. Coding Instructions

• Objective: Document the resident's discharge performance in toileting hygiene accurately.
• 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 88 if the activity did not occur during the assessment period.

4. Coding Tips

• Consider the resident’s most dependent episode of toileting hygiene near discharge for coding.
• Review all available documentation and consult with the interdisciplinary team to ensure an accurate assessment of the resident’s discharge abilities.

5. Documentation

• Objective: Ensure detailed documentation of the resident's discharge performance in toileting hygiene.
• Key Points:
  • Record observations of the resident's toileting hygiene routines, noting any required assistance or use of adaptive equipment.
  • Document any interventions or training provided to improve toileting hygiene and the resident's response to these efforts.

6. Common Errors to Avoid

• Coding based on the resident’s abilities at admission rather than discharge.
• Failing to document improvements or declines in toileting hygiene ability observed during the stay.

7. Practical Application

• Scenario: Mr. Alex Martinez has made significant improvements in his ability to manage toileting hygiene during his stay, moving from needing substantial assistance to only requiring setup assistance for toileting hygiene tasks by discharge. His discharge assessment reflects this progress, with occupational therapy notes supporting his improved independence. Therefore, the MDS Coordinator codes his toileting hygiene performance as 5 (setup or clean-up assistance) in GG0130C3.

The Step-by-Step Coding Guide for item GG0130C3 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.