GG0130E3: Shower/Bathe Self (Discharge Performance), Step-by-Step
Step-by-Step Coding Guide for GG0130E3: Shower/Bathe Self (Discharge Performance)
1. Review of Medical Records
Objective: Assess the resident’s ability to shower or bathe independently during the discharge assessment period.
Actions:
- Review the resident’s nursing notes, therapy records, and other self-care documentation.
- Observe or obtain feedback on how much assistance the resident required for washing, rinsing, and drying their body during showering or bathing.
2. Understanding Definitions
GG0130E3: Shower/Bathe Self: This item captures the resident’s ability to wash, rinse, and dry their body, excluding transfers into or out of the tub or shower. The assessment includes the face, upper body, lower body, and perineal area, but not the resident’s back or hair.
Example Scenarios:
- Resident A: The resident bathes independently while seated on a tub bench. A nurse sets up bathing supplies, but no further assistance is needed. This would be coded as 05: Setup or clean-up assistance.
3. Coding Instructions
Step-by-Step:
- Step 1: Determine the resident’s ability to wash, rinse, and dry their body.
- Step 2: Identify the level of assistance required:
- 06: Independent: Resident performs all tasks without any assistance.
- 05: Setup or clean-up assistance: Resident requires help only with setting up or retrieving bathing supplies.
- 04: Supervision or touching assistance: A helper provides verbal cues or light touch.
- 03: Partial/moderate assistance: Helper provides less than half the effort.
- 02: Substantial/maximal assistance: Helper provides more than half the effort.
- 01: Dependent: The resident requires two or more helpers for bathing.
Illustration:
- Scenario: Resident B is able to wash their face and chest but requires help washing the lower body due to limited range of motion. This would be coded as 03: Partial/moderate assistance.
4. Coding Tips
- Exclude Transfers: Do not consider assistance for getting in or out of the tub or shower; this is covered in a different item.
- Environment Flexibility: Bathing can be performed in various settings, including showers, tubs, or sponge baths at a sink or in bed.
5. Documentation
Objective: Clearly document the resident’s performance during bathing, including the amount of assistance and any adaptive equipment used.
Actions:
- Record how much of the task was completed independently versus with help.
- Note any assistive devices used, such as bath benches or handheld showerheads.
6. Common Errors to Avoid
- Incorrectly Coding Transfers: Ensure that assistance with transfers (e.g., getting into or out of the tub) is not included in this item.
- Incomplete Documentation: Do not code GG0130E3 without thorough documentation of the resident’s ability and any assistance provided.
7. Practical Application
- Example 1: A resident washes their body independently while sitting on a shower chair but needs assistance setting up supplies. This would be coded as 05: Setup or clean-up assistance.
- Example 2: A resident requires a helper to wash their entire body due to limited mobility. Code this as 01: Dependent.
Please note that the information provided in this guide for MDS 3.0 Item set GG0130E3 was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0.
The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding.
Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.
