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

Slide Handouts: Documentation to Support MDS Section GG

Pdf Summary

The "PDPM Documentation Essentials– Documentation Sections GG" module by AAPACN (2025) provides comprehensive guidance for nursing and interdisciplinary teams on accurately documenting Section GG of the Minimum Data Set (MDS), which focuses on residents' self-care and mobility functional status under the Patient-Driven Payment Model (PDPM).

Key points include:

1. <strong>Section GG Overview</strong>: This section captures a resident's usual performance in self-care (GG0130) and mobility (GG0170) during specified assessment periods (e.g., 5-Day Admission, Interim Payment Assessment, Discharge). Usual performance is defined as the resident's typical, baseline functional ability over the 3-day look-back period, avoiding extremes of best or worst performance.

2. <strong>Assessment Process</strong>: Accurate coding requires direct observation combined with reports from qualified clinicians, care staff, or family. Residents are encouraged to perform tasks as independently as safely possible, including use of assistive devices. “Helper” assistance is limited to facility employed or contracted staff; family or external caregivers are excluded.

3. <strong>Performance Scale</strong>: Scoring ranges from Independent (no help) to Dependent (full assistance or two helpers), with intermediate levels including setup help, supervision, partial/moderate, and substantial/maximal assistance. Activities not attempted due to refusal or medical conditions are distinctly coded.

4. <strong>Documentation Examples and Best Practices</strong>: Detailed examples illustrate documenting activities such as eating, oral hygiene, toileting hygiene, transfers, walking, and mobility maneuvers like sit-to-stand or lying-to-sitting. Thorough narrative notes support MDS coding by detailing the type and amount of assistance, resident conditions, and any equipment used.

5. <strong>Supporting Documentation</strong>: While CMS does not mandate specific forms, documentation must reflect ongoing monitoring during the 3-day assessment period with interdisciplinary input. It should reflect usual performance and exclude assistance provided solely for convenience or potential capability assessments.

6. <strong>Educational Tools</strong>: The module includes tip sheets, decision trees, data collection tools, and quizzes to enhance understanding.

Overall, this educational module equips clinicians with the knowledge to accurately assess and document residents' functional status in Section GG, ensuring compliance with federal regulations and supporting appropriate PDPM reimbursement.

Keywords

PDPM

Section GG

Minimum Data Set

self-care

mobility

functional status

nursing documentation

assessment process

performance scale

AAPACN