Understanding and Coding MDS 3.0 Item GG0130F3: Upper Body Dressing (Discharge Performance)

Introduction

Purpose:
MDS 3.0 Item GG0130F3 assesses a resident’s performance in upper body dressing at the time of discharge. This item evaluates how much assistance the resident needed to put on and remove clothing during the days leading up to discharge, providing valuable information on the resident’s progress and care needs upon leaving the facility.

What is MDS Item GG0130F3?

Explanation:
GG0130F3 captures the level of assistance required for upper body dressing at discharge, specifically focusing on shirts, sweaters, and other upper body garments. This item helps track changes in functional ability between admission and discharge, informing after-care planning and therapy decisions.

Guidelines for Coding GG0130F3

Coding Instructions:
Code GG0130F3 using the same six-point scale as for admission:

• 06 (Independent): Resident completes the activity on their own.
• 05 (Setup or clean-up assistance): Resident can dress but needs someone to set up clothing.
• 04 (Supervision or touching assistance): Resident needs supervision or minimal touch assistance.
• 03 (Partial/moderate assistance): Resident performs more than half of the effort but needs help with certain parts.
• 02 (Substantial/maximal assistance): Resident does less than half of the task and requires significant help.
• 01 (Dependent): Helper performs the entire task.

Example Scenario:
At discharge, Resident Y can put on a pullover shirt but still needs help fastening buttons and adjusting the garment. This performance would be coded as 03 (Partial/moderate assistance).

Best Practices for Accurate Coding

Documentation:

Ensure the discharge assessment accurately reflects the resident’s performance during the last three days before discharge. Cross-reference progress notes and feedback from occupational therapists.

Communication:

Facilitate communication between interdisciplinary team members to ensure the discharge performance coding reflects the resident’s actual abilities.

Training:

Provide regular training on assessing discharge performance to ensure coding reflects the true level of resident independence.

Conclusion

Summary:
Accurately coding GG0130F3 is essential for understanding a resident's progress and for planning post-discharge care. Ensuring accurate documentation and interdisciplinary communication helps tailor the care plan for the next stage of recovery.

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

Reference

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-30 for detailed guidance on coding this item.

Disclaimer

This information is based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024.