As you are aware, Section GG had the most changes in the MDS revisions effective October 1, 2018, including adding 36 new items, modifying existing text, and changes to when the inactivity codes should be used.
All Section GG new item additions focus on patient function with coding on the admission and discharge assessments. While the “Everyday Activities” focus on the resident’s usual ability prior to the current illness, exacerbation, or injury, the items added to “Self-Care” and “Mobility” should be coded based upon the patient’s “usual performance”, presumably during the first three days of a resident’s SNF stay, which is unchanged from the previous instruction.
Since all of the new items are function focused; most items would logically be captured exclusively by the therapy team. However, that does not mean that section GG should be completed only by the therapy team.
It appears easy and time saving to allow therapy or nursing alone to capture the section GG items. Many in the industry advise against this practice. While Prime Rehabilitation Services therapists are highly skilled in capturing this type of data, patients often behave differently in therapy than they do with nursing staff, on the floor or in their room. Simply having therapy capture Section GG data without any nursing input may not be the “usual performance” and likely will give an inaccurate picture of the patients’ functional abilities.
All this additional data required in Section GG does necessitate increased collaboration between nursing and therapy perhaps in this way:
- Prime Rehabilitation Services captures section GG information electronically on evaluation using Optima Therapy tools.
- Nursing captures section GG information on days 1–3 of the patient’s stay.
- Therapy/Nursing/MDS collaboration should occur on about day 3 or 4 of the patient’s stay, to discuss section GG items and determine the appropriate level to code on the Admission assessment within the MDS, insuring that documentation supports the coding decided.
The same collaboration for the Discharge Assessment.
This raises the next question, what’s your plan for collecting the data if therapy is not involved/not ordered?