Q0310: Resident's Overall Goal

Step-by-Step Coding Guide for Q0310: Resident’s Overall Goal

1. Review of Medical Records

• Objective: Start by thoroughly reviewing the resident’s medical records to identify any documented goals or objectives set by or for the resident. This can include goals related to care, treatment, rehabilitation, and personal aspirations.
• Key Documents to Review: Care plans, therapy notes, social services documentation, and notes from resident and family meetings.

2. Understanding Definitions

• Resident's Overall Goal: This refers to the primary aim or objective the resident hopes to achieve during their stay in the facility, which can encompass a wide range of areas including health status, mobility, social engagement, or transitioning back to the community.

3. Coding Instructions

For Q0310, you would typically code based on the resident’s expressed goals, as documented in the care plan or through discussions with the resident and their family:

• Code options might include: Improvement in physical function, maintenance of current status, other specific goals, or no goals identified.

4. Coding Tips

• Engage directly with the resident (and family, if applicable) to understand and document their goals accurately.
• Ensure goals are SMART (Specific, Measurable, Achievable, Relevant, Time-bound) when possible, to facilitate clear coding and tracking of progress.

5. Documentation

• Clearly document the resident's overall goal in their care plan, including any specific targets, expected outcomes, and the proposed timeline.
• Include notes from discussions with the resident and their family about the goal-setting process.

6. Common Errors to Avoid

• Vague Goals: Avoid documenting goals that are too broad or vague, which can be difficult to code and measure.
• Failure to Update Goals: Goals should be revisited and documented regularly to reflect any changes in the resident’s condition or preferences.
• Not Involving the Resident: Always ensure the resident is involved in setting their own goals to the greatest extent possible.

7. Practical Application

Example Scenario: A resident admitted for short-term rehabilitation following a stroke expresses a goal to regain enough mobility to walk independently with a cane within three months.

• Documentation Needed: The care plan should detail this goal, along with the specific interventions planned to achieve it, such as physical therapy frequency and milestones for progress.
• Coding: Based on Q0310 options, code to reflect the resident’s specific goal of improved physical function with a defined timeline.

The Step-by-Step Coding Guide for item Q0310 in MDS 3.0 Section Q is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Please note that healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.