General Section
DIRACHART — SKILLED DOCUMENTATION · NURSING HOMES (DGEX-SNF)
DiraChart Clinical Reference · Read-only reference edition
Clinical Reference · 2.9
ADL & Functional Documentation (Section GG)
How to document ADL and functional performance so MDS Section GG is accurate and the PDPM function score is defensible — the 6-level usual-performance scale over the assessment window, the multi-shift interdisciplinary capture, and the difference between a coding observation and a skilled service.
Module code | SNF-FUNCTIONAL-GG |
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Version | 1.0 · Population: Adult · DiraChart reference edition |
Used alongside | Restorative · Musculoskeletal · Skilled-Daily · Falls |
MDS section(s) | GG0130 (self-care) and GG0170 (mobility) — admission/discharge performance and goals; the PDPM function score |
Survey F-tag(s) | F676 (maintain abilities) · F677 (ADL care for dependent residents) · F684 |
How to use this module Fill every model note and smart phrase with the shift’s actual values and the resident’s current orders — these are structured examples to edit, never phrases to copy. The universal writing rules in Foundations (the necessity sentence, quantified outcomes, teach-back, closed-loop coordination, MDS-supportive documentation, and care-plan linkage) apply throughout and are not reprinted here. Disease-specific days route to the overlays. Verify each threshold and citation against the current source before use. |
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