GG Charting
Dorothy only needs setup/clean-up assistance from one staff member.
05- Setup/Clean-up assistance
Millie eats all meals without any physical assistance or supervision from a staff member. She has a gastrostomy tube (G-tube), but it is no longer used, and it will be removed later today.
Eating would be documented as 06, Independent.
Rationale: The resident can independently complete the activity without any assistance from a staff member for this activity. In this scenario, the presence of a G-tube does not affect the eating score.
Mr. Franks medical conditions include morbid obesity, diabetes mellitus, and sepsis, and he recently underwent bilateral above-the-knee amputations. Mr. Frank requires full assistance with transfers from the bed to the wheelchair using a lift device. Two staff members are required for safety when using the device to transfer Mr. Franks from the bed to a wheelchair. Mr. Franks is unable to assist in the transfer from his bed to the wheelchair.
01, Dependent
Rationale: The two staff members completed all the effort for the activity of chair/bed-to-chair transfer. If two or more staff members are required to assist the resident to complete an activity, code as 01, Dependent.
Mrs. Jenkins has right-side upper extremity weakness as a result of a stroke and has worked in therapy to relearn how to dress her upper body. During the day, she requires a staff member only to place her clothing next to her bedside. Mrs. Jenkins can now use compensatory strategies to put on her bra and top without any assistance. At night she removes her top and bra independently and puts the clothes on the nightstand, and the staff member puts them away in her dresser.
05, Setup or clean-up assistance.
Rationale: Mrs. Jenkins dresses and undresses her upper body and requires a helper only to retrieve and put away her clothing, that is, setting up the clothing for her use. The description refers to Mrs. Jenkins as “independent” (when removing clothes), but she needs setup assistance, so she is not independent with regard to the entire activity of upper body dressing.
Rose has severe joint degenerative disease and is recovering from sepsis. Upon discharge Rose will need to be able to walk on the uneven and sloping surfaces of her driveway. During her stay at Shady Pines, a physical therapist takes Rose outside to walk on uneven surfaces. Rose requires the therapist’s weight-bearing assistance less than half the time during walking in order to prevent Rose from falling as she navigates walking 10 feet over uneven surfaces.
03, Partial/moderate assistance
Rationale: Rose requires a staff member to provide weight-bearing assistance several times to prevent her from falling as she walks 10 feet on uneven surfaces. The staff member contributes less than half the effort required for Rose to walk 10 feet on uneven surfaces.
Blanche only needs verbal/nonverbal cueing or steadying/touching/contact guard assistance from one staff member.
04- Supervision/touching assistance
In the morning and at night, Mrs. Franks brushes her teeth while sitting on the side of the bed. Each time, the staff member gathers her toothbrush, toothpaste, water, and an empty cup and puts them on the bedside table for her before leaving the room. Once Mrs. Franks is finished brushing her teeth, which she does without any help, the staff member returns to gather her items and dispose of the waste.
05, Setup or clean-up assistance.
Rationale: The staff member provides setup and clean-up assistance. The resident brushes her teeth without any help.
At night, the staff member provides Mrs. Robins water and toothpaste to clean her dentures. Mrs. Robins cleans her upper denture plate. Mrs. Robins then cleans half of her lower denture plate, but states she is tired and unable to finish cleaning her lower denture plate. The staff member finishes cleaning the lower denture plate and Mrs. Robins replaces the dentures in her mouth.
03, Partial/moderate assistance
Rationale: The helper provided less than half the effort to complete
Mrs. McMann has peripheral neuropathy in her upper and lower extremities. Each morning, Mrs. McMann needs assistance from a staff member to place her lower limb into, or to take it out of (don/doff), her lower limb prosthesis. She needs no assistance to put on and remove her underwear or slacks.
03, Partial/moderate assistance.
Rationale: A helper performs less than half the effort of lower body dressing (with a prosthesis considered a piece of clothing). The helper lifts, holds, or supports Mrs. McManns trunk or limbs, but provides less than half the effort for the task of lower body dressing.
Rose needs physical assistance with trunk support from one staff member with the staff member providing LESS THAN HALF OF THE EFFORT.
03- Partial/moderate assistance
Mrs. Good uses the toilet to void and have bowel movements. Mrs. Good is unsteady, so the staff member walks into the bathroom with her in case she needs help. During the assessment period, a staff member has been present in the bathroom, but has not needed to provide any physical assistance with managing clothes or cleansing.
04, Supervision or touching assistance.
Rationale: The staff member provides supervision as the resident performs the toilet hygiene activity. The resident is unsteady and the staff provide supervision for safety reasons.
True or false- Documentation in caretracker needs to be completed by the end of your shift.
True
Notify RNS or RNP nurse if not able to log into computer/Caretracker and/or not able to finish charting for end of your shift.
Birtha was admitted to nursing home for a neurologic condition and experiences visual impairment and fine motor coordination and endurance issues. She requires setup for retrieving her socks and shoes, which she prefers to keep in the closet. Birtha often drops her shoes and socks as she attempts to put them onto her feet or as she takes them off. A staff member must first thread her socks or shoes over her toes, and then Birtha can complete the task. Birtha needs the staff member to initiate taking off her socks and unstrapping the Velcro used for fastening her shoes.
02, Substantial/maximal assistance.
Rationale- A helper provides Birtha with assistance in initiating putting on and taking off her footwear because of her limitations regarding fine motor coordination when putting on/taking off footwear. The helper completes more than half of the effort with this activity.
Angela needs physical assistance with lifting and trunk support from one staff member with the staff member providing MORE THAN HALF OF THE EFFORT.
02- Substantial/maximal assistance
Mrs. Hewlett suffered a pelvic fracture during a motor vehicle accident. Mrs. Hewlett requires the staff member to lift and position her left leg when she transfers from sitting at the edge of the bed to lying flat on the bed due to severe pain in her left pelvic area. Mrs. Hewlett uses her arms to position and lower her upper body to lying flat on the bed.
03, Partial/moderate assistance.
Rationale: A staff member lifts Mrs. Hewletts left leg and helps her position it as Mrs. Hewlett transitions from a seated to a lying position; the helper does LESS THAN HALF OF THE EFFORT.
Mr. Thompson walks 10 feet with staff member providing trunk support. He also requires a second staff member who provides supervision and follows closely behind with a wheelchair for safety. Mr. Thompson walks the 10 feet with two turns with the assistance of two helpers.
01, Dependent.
Rationale: Mr. T requires two staff members to complete the activity.
Mr. Z had a stroke that resulted in paralysis on his right side and is recovering from cardiac surgery. He requires the assistance of two staff members when rolling onto his right side and returning to lying on his back and also when rolling onto his left side and returning to lying on his back.
01, Dependent
Rationale: Two staff members are needed to help Mr. Z roll onto his left and right side and back while in bed.
Sophia walks 10 feet with her physical therapist using a gait belt around her trunk and the therapist supports less than half of the effort while she holds the hallway handrail.
03, Partial/moderate assistance.
The staff member provides less than half the required effort in providing the necessary support for Sophia as she walks 10 feet.
Sophia requires the staff member to provide all the effort to complete ADL.
or
Sophia requires assistance of 2 or more staff members to complete ADL.
01- Dependent
Mr. Bart pushes up on the bed to attempt to get himself from a lying to a seated position as the occupational therapist provides much of the lifting assistance necessary for him to sit upright. The occupational therapist provides additional lifting assistance as Mr. Bart scoots himself to the edge of the bed and lowers his feet to the floor.
02, Substantial/maximal assistance.
Rationale: The staff member provides lifting assistance (MORE THAN HALF THE EFFORT) as the resident moves from a lying to sitting position.
Mr. Young has limited mobility resulting from his multiple and complex medical conditions. He prefers to wash his body while sitting in front of the sink in his bathroom. A staff member assists with washing, rinsing, and drying Mr. Youngs arms/hands, upper legs, lower legs, buttocks, and back.
02, Substantial/maximal assistance
Rationale: The helper completed more than half the activity. Bathing may occur at the sink. When coding this activity, do not include assistance provided with washing, rinsing, or drying the resident’s back
During her stay at Shady Pines Sophia works with an occupational therapist on transfers in and out of the passenger side of a car. On the day before discharge, when performing car transfers, Sophia requires verbal reminders for safety and light touching assistance. The therapist instructs her on strategic hand placement while Sophia transitions to sitting in the car’s passenger seat. The therapist opens and closes the door.
04, Supervision or touching assistance
Rationale: The staff member provides touching assistance as the resident transfers into the passenger seat of the car. Assistance with opening and closing the car door is not included in the definition of this item and is not considered when coding this item.