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Section GG Toolkit

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Ensure accurate coding and competency in your facility with the Section GG Toolkit, designed to support SNF/LTC staff in mastering the assessment and reporting of functional abilities in compliance with CMS guidelines. This toolkit provides practical resources for training and competency evaluation, including post-tests, case study videos, coding worksheets, and evaluation forms for Section GG of the MDS. Ideal for onboarding, annual reviews, or when gaps in competency are identified, this toolkit aids in maintaining compliance, enhancing staff skills, and supporting your facility's QAPI and Compliance programs.

Strengthen Restorative Nursing Documentation with the Section GG Toolkit

Accurate documentation of functional status is critical for restorative nursing programs, resident outcomes, and facility compliance. This toolkit gives your team the resources to streamline assessment, track progress, and ensure your records reflect the true level of care provided.

Inside the toolkit, you’ll find:

  • Documentation Review & Accuracy Audit Tool — quickly identify gaps and improve record-keeping.

  • Observation Worksheets — ensure staff assessments align with resident care and MDS coding.

  • Admission, Discharge, and Interim Documentation Forms — standardize workflows and reduce errors.

  • Function Score Quick Reference Sheet — simplify scoring and strengthen outcomes tracking.

  • MDS Section GG Coding Policy Example — build consistent policies to support program success.

Why it matters:

Your restorative nursing program is only as strong as your documentation and tracking. Section GG is central to demonstrating resident functional gains, supporting regulatory compliance, and informing PDPM/MDS accuracy. This toolkit helps your team implement best practices and reduces the risk of errors or gaps in record-keeping.

Equip your restorative nursing team with the tools to document, track, and improve outcomes — and make survey readiness a seamless part of your workflow.

Contents

Toolkit Guide

This toolkit can be used to prepare front line and coding staff for appropriate assessment, reporting and coding of section GG according to the RAI manual. This toolkit focuses on basic coding definitions and guidance as documented within the RAI manual for section GG.

Practice case study videos and coding worksheets are provided in this toolkit which may be used to facilitate learning activities, group discussion, and skill testing. Extra practice scenarios are provided for use for those needing additional coaching or to vary content of periodic educational sessions.

In follow up to training, it is recommended that the coding observation tool and documentation and accuracy audit tool be used to conduct periodic Auditing and Monitoring activities in coordination with facility QAPI and/or SNF Compliance and Ethics Program work plans.

Additional Resources & Tools:

1. MDS Section GG Coding Policy

2. Section GG Function Score Quick Tips

3. Section GG Items Directly Impact SNF QRP Measures

4. Section GG Admission Documentation (8hr and 12 hr shift)

5. Section GG Discharge Documentation (8 hrs & 12 hr shift)

6. Section GG OBRA / Interim Documentation (8 hrs & 12 hr shift)

7. Section GG IPA Documentation (8 hrs & 12 hr shift)

1. Toolkit Guide.pdf
  • 261 KB

Power Point Presentation for Staff Training

Present the material using the power point slides and resources based on your facility needs. Suggested training format:

• Orientation/Annual Training/Remediation: Use the PowerPoint™ slides and instructor guidance below to conduct inservice training for staff. Following the training, assess staff competency on Section GG coding skills using the post tests and Competency Evaluation forms provided.

• The suggested outline and time required for each phase of training is:

Introduction of Instructor, Topic, & Objectives - 5 minutes

Part 1: Lecture for those with MDS coding responsibilities - 20 minutes

Part 2: Interactive Lecture with Power Point and Video Case Studies -45 minutes

Post Test - 15 minutes

Review Key Take-Away Points Question & Answer - 5 minutes

Extra Practice Video Case Studies (as needed) - 10 minutes

Total: 100 minutes

Interactive Lecture

With this method you present the material, using questions-and-answers, video case study scenarios and the provided PowerPoint™ slides. During your lecture, be sure to personalize the presentation as much as possible using real life facility examples, process review and data collection instructions. Utilize the speaker notes to guide discussion throughout the presentation and coding for each video case study scenario.

SPEAKER NOTES ARE LOCATED IN THE NOTES SECTION OF THE POWERPOINT™

Slides 1-21: Focus on information for those with MDS coding responsibilities.

Slides 22- last slide: Focus on information for those with responsibilities for observing, assessing, and reporting functional abilities based on Section GG requirements.

The PowerPoint™ presentation provided includes videos which can be accessed individually via web-based YouTube™ links (internet connection required).

2. Section GG Toolkit PowerPoint Presentation.pptx
  • 35.1 MB

Section GG Coding Training Activity Worksheet – Case Studies

4. Section GG Coding Worksheet - Case Studies with Answer Key.pdf
  • 155 KB
3. Section GG Coding Worksheet - Case Studies.pdf
  • 1.75 MB

Section GG Observation Tool

Directions:

For up to 4 residents, observe the nurse, therapist, or CNA as they assess or observe a resident’s ability to complete any of the GG activities listed on the tool.

Indicate in the “Staff Coding Selection/Description” column the GG performance or activity not attempted code chosen by the individual being observed.

Indicate whether the chosen code is assigned correctly in the “Accurate” column (yes/no).

If the auditor observes an activity and disagrees with the employee’s coding decision, describe the discrepancy & accurate performance code in the “Comments” column.

Note: It is not required to assess all items for the same resident but may be helpful to assess any one item for multiple residents.

5. Section GG Observation Tool.pdf
  • 1.16 MB

Section GG Documentation Review and Accuracy Audit Tool

Directions:

Identify the usual performance code reported for each self-care and mobility item in Section GG. Gather source documents in in the record to support the MDS coding decision.

Determine Yes/No if the usual performance code is effectively supported.

6. Section GG Documentation and Coding Accuracy Audit.pdf
  • 220 KB

Sample MDS Section GG Coding Policy

7. MDS Section GG Coding Policy Example.pdf
  • 221 KB

Section GG Function Score Quick Tips

8. Section GG Function Score Quick Tips.pdf
  • 320 KB

Section GG Items Impact on SNF QRP Measures

9. Section GG Items Directly Impact SNF QRP Measures.pdf
  • 122 KB

Section GG Documentation Forms

10. Section GG Admission Documentation (8 hr shift).pdf
  • 180 KB
11. Section GG Admission Documentation (12 hr shift).pdf
  • 172 KB
15. Section GG OBRA-Interim Documentation (12 hr shift).pdf
  • 197 KB
13. Section GG Discharge Documentation (12 hr shift).pdf
  • 172 KB
12. Section GG Discharge Documentation (8 hr shift).pdf
  • 181 KB
16. Section GG IPA Documentation (8 hr shift).pdf
  • 153 KB
14. Section GG OBRA-Interim Documentation (8 hr shift).pdf
  • 205 KB
17. Section GG IPA Documentation (12 hr shift).pdf
  • 150 KB