Understanding and Coding MDS 3.0 Item GG0100A: Self-Care - Prior Functioning

Understanding and Coding MDS 3.0 Item GG0100A: Self-Care - Prior Functioning

Introduction

Purpose: Understanding a resident’s prior level of functioning is crucial to developing a personalized care plan. MDS Item GG0100A assesses the resident’s ability to perform self-care tasks before their current illness, injury, or admission to the facility. This information is vital in determining the resident’s baseline abilities and setting realistic goals for rehabilitation or ongoing care. Accurately assessing prior functioning helps ensure that the resident receives care that aligns with their previous capabilities and overall needs.

What is MDS Item GG0100A?

Explanation: MDS Item GG0100A is part of Section GG: Functional Abilities and Goals, which focuses on a resident's functional abilities both in the present and in the past. Specifically, GG0100A addresses the resident’s self-care abilities before the current illness, injury, or admission. Self-care activities include essential daily tasks such as bathing, dressing, grooming, and feeding. This item provides insight into the resident’s prior independence and helps create a care plan that promotes recovery or maintenance of their previous functional status.

Guidelines for Conducting and Coding MDS Item GG0100A

Conducting the Assessment: Staff must gather information about the resident’s self-care abilities before their current illness or admission. This information can come from:

• Interviews with the resident or family members
• Medical records or previous health assessments
• Observations from caregivers who provided care prior to admission

The focus is on determining how independently the resident performed self-care tasks, such as bathing, dressing, toileting, and feeding.

Coding Instructions: MDS Item GG0100A uses a scale to reflect the level of independence the resident had prior to their illness or admission. The coding options are:

• 3 - Independent: The resident was able to perform all self-care tasks independently without any assistance.
• 2 - Needed Some Help: The resident required some help from another person to complete self-care tasks.
• 1 - Dependent: The resident was completely dependent on another person for self-care.
• 8 - Unknown: Information about the resident’s prior self-care abilities is not available.
• 9 - Not Applicable: The resident’s self-care abilities prior to the current illness or admission are not relevant.

Example Scenario: If a resident was able to bathe, dress, and feed themselves with no assistance before admission, you would code GG0100A as 3 - Independent. If the resident needed help with some tasks, you would code GG0100A as 2 - Needed Some Help. If no information is available about their prior self-care abilities, code GG0100A as 8 - Unknown.

Best Practices for Accurate Coding

Gather Reliable Information: It is essential to gather accurate and reliable information about the resident’s prior self-care abilities from family members, medical records, or previous caregivers. This will help ensure the coding accurately reflects the resident’s baseline functioning.

Thorough Documentation: Document the sources of information used to assess the resident’s prior self-care abilities. Whether the information is obtained from family interviews, medical records, or past caregivers, clear documentation is necessary to support the assessment.

Collaboration with the Care Team: Share the results of the assessment with the interdisciplinary care team. Understanding the resident’s prior self-care abilities helps guide rehabilitation goals and ensures that the resident’s care plan supports their return to the highest possible level of independence.

Conclusion

Summary: MDS Item GG0100A is an essential part of assessing a resident’s prior functional abilities in self-care before their illness or admission to a long-term care facility. Accurately assessing and documenting this information helps create a care plan that supports the resident’s recovery and enhances their quality of life.

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

Reference

This guide is based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024, Page GG-4.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item GG0100A: "Self-Care - Prior Functioning" 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. Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice.