Understanding and Coding MDS 3.0 Item GG0130F1: Upper Body Dressing (Admission Performance)

Understanding and Coding MDS 3.0 Item GG0130F1: Upper Body Dressing (Admission Performance)

Introduction

Purpose:
MDS Item GG0130F1 evaluates a resident’s performance in upper body dressing at the time of admission. This item assesses how much assistance the resident requires to put on and remove upper body garments such as shirts, sweaters, and nightgowns. Accurately coding this item helps ensure that appropriate care and rehabilitation services are provided.

What is MDS Item GG0130F1?

Explanation:
GG0130F1 captures the level of assistance a resident needs to complete upper body dressing during the admission process. This includes donning and doffing garments and any required medical devices that count as clothing, such as orthoses or compression stockings. This assessment determines the level of independence or support the resident needs, influencing their care plan and therapy goals.

Guidelines for Coding GG0130F1

Coding Instructions:
Code GG0130F1 based on the following six-point scale, according to how much assistance the resident requires:

• 06 (Independent): Resident completes the activity by themselves without assistance.
• 05 (Setup or clean-up assistance): Resident dresses independently but requires setup or clean-up by a helper, such as retrieving clothing.
• 04 (Supervision or touching assistance): Resident needs supervision or light touch to safely complete the task.
• 03 (Partial/moderate assistance): Resident performs more than half of the dressing effort but requires help for the rest.
• 02 (Substantial/maximal assistance): Resident performs less than half the effort; a helper must complete most of the task.
• 01 (Dependent): Resident is unable to participate in the activity, and the helper performs all of it.

Example Scenario:
Resident X can pull their shirt over their head but needs assistance to button it and adjust their sleeves. In this case, you would code GG0130F1 as 03 (Partial/moderate assistance) since the resident completes more than half of the task but requires help with the final steps.

Best Practices for Accurate Coding

Documentation:

Ensure accurate documentation by recording the resident’s observed performance during the first three days of their stay. Review medical records and consult with nursing staff for a complete picture of the resident’s abilities.

Communication:

Interdisciplinary communication is key. Regularly discuss the resident’s functional abilities with occupational therapists, nurses, and caregivers to ensure consistent coding across all assessments.

Training:

Ensure that staff members involved in coding are well-trained in the use of the six-point scale and understand how to assess the resident's true ability without influencing their performance.

Conclusion

Summary:
Coding GG0130F1 correctly ensures that residents receive the appropriate level of care and therapy during their stay. Accurate assessments help tailor care plans to each resident's specific needs, improving overall outcomes and promoting better quality of life.

Click here to see a detailed Step-by-Step on how to complete this item set.

Reference

For detailed coding instructions, please refer to the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024, Chapter 3, Page GG-28.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item set GG0130F1 was originally based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. 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.