PDPM Documentation Essentials for the IDT: Documentation to Support MDS Section GG-Additional Handouts

Additional Handouts

Pdf Summary

The 2025 AAPACN Section GG Daily and Usual Performance Documentation Tip Sheets provide guidance for consistent, precise assessment documentation of residents' functional abilities in long-term care. The materials emphasize the importance of documenting actual resident performance, support required, and use of assistance or equipment, not just capabilities, following facility policies and regulations.<br /><br />Section GG focuses on self-care (eating, oral hygiene, toileting hygiene, bathing, dressing, personal hygiene) and mobility tasks (rolling, transfers, walking various distances, stair navigation, object picking, wheelchair use). Definitions clarify each task’s functional criteria, such as the ability to use utensils to eat or transfer safely with cues or physical assistance.<br /><br />Documentation should record levels of helper assistance—from setup only to full dependence—number of helpers, and any equipment used. Only facility-employed or contracted staff count as helpers, excluding external personnel like hospice or student aides. When assessing usual performance over a three-day window, clinicians should note fluctuations and document rationale for identifying baseline function. An interdisciplinary team of qualified practitioners must oversee assessments.<br /><br />Section GG assessment periods vary by type: admission, interim, and discharge assessments have specific three-day look-back windows tied to dates such as admission date (A1600), Medicare Part A stay dates (A2400B/C), or discharge date (A2000). Discharge assessment periods can be complex, especially for combined OBRA and PPS assessments, with decision trees and algorithms guiding accurate computation of assessment windows.<br /><br />Scoring uses a 01-10 and special codes system reflecting dependence level, assistance type, refusals, or if activities were not attempted due to medical or environmental reasons. This coding aligns with CMS’s RAI manual requirements to support accurate Minimum Data Set (MDS) reporting for care planning and reimbursement.<br /><br />Overall, the guidance ensures that assessments capture a reliable, nuanced picture of each resident’s functional status, enabling quality monitoring and compliance with federal regulations.

Keywords

AAPACN

Section GG

Daily and Usual Performance

Functional Abilities

Long-term Care

Self-care Tasks

Mobility Tasks

Assessment Documentation

Helper Assistance Levels

Minimum Data Set (MDS)