Step-by-Step Coding Guide for Item Set Q0550A: Reasking Resident Preference

This guide facilitates the accurate coding of efforts to reassess a resident's preferences as outlined in Q0550A of the MDS 3.0.

1. Review of Medical Records

• Objective: To determine whether the resident's preferences have been reasked or reassessed since the last MDS assessment.
• Key Points:
  • Thoroughly review the resident's medical records, including care plans, progress notes, and any documented resident council or family meeting notes, for evidence of reassessment of preferences.
  • Pay special attention to documentation following significant events, such as hospitalizations or changes in health status, which might prompt a reevaluation of preferences.

2. Understanding Definitions

• Objective: Clarify what constitutes "Reasking Resident Preference."
• Key Points:
  • Reasking Resident Preference: Involves revisiting discussions with the resident about their care preferences, lifestyle choices, and goals to ensure that care planning remains aligned with their wishes, especially after changes in condition or at regular intervals.

3. Coding Instructions

• Objective: Guide on how to accurately code for reassessment of resident preferences.
• Key Points:
  • Code 1: If there is documented evidence that the resident's preferences have been reassessed since the last MDS coding period.
  • Code 0: If there is no evidence of reassessment of the resident's preferences since the last MDS coding period.

4. Coding Tips

• Ensure documentation is clear and specific about the date and outcome of reassessment conversations.
• Consider routine care planning reviews as opportunities to reassess preferences, documenting any confirmations or changes in the resident's wishes.

5. Documentation

• Clearly document in the resident's records the process of reasking preferences, including who was involved, the questions asked, the resident's responses, and any changes or confirmations to previous preferences.
• Note the date of the reassessment to easily track when preferences were last reviewed.

6. Common Errors to Avoid

• Failing to document the reassessment of preferences, even if conversations have occurred, leading to inaccuracies in coding.
• Overlooking the need to reassess preferences after significant changes in the resident's condition or situation.

7. Practical Application

• Scenario: A resident who previously expressed a preference for not participating in group activities has become more socially engaged after moving to a different room closer to communal areas. A staff member revisits this preference with the resident, documenting the conversation in which the resident now expresses interest in selected group activities.

The Step-by-Step Coding Guide for item Q0550A 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. 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.