Understanding and Coding MDS 3.0 Item Q0110C: Assessment and Goal Participation: Significant Other

Understanding and Coding MDS 3.0 Item Q0110C: "Assessment and Goal Participation: Significant Other"

Introduction

Purpose:
In long-term care settings, the involvement of a resident’s significant other in the assessment and goal-setting process can be crucial to ensuring that the resident’s preferences and needs are accurately reflected in their care plan. MDS Item Q0110C, "Assessment and Goal Participation: Significant Other," is used to document the participation of a resident’s significant other in these discussions. This item ensures that the resident’s care plan includes input from those closest to them, thereby supporting a person-centered approach to care. This article provides detailed guidance on how to correctly code this item to ensure accurate documentation and compliance with CMS standards.

What is MDS Item Q0110C?

Explanation:
MDS Item Q0110C, "Assessment and Goal Participation: Significant Other," is part of Section Q, which focuses on the resident’s involvement in goal setting and discharge planning. This item specifically captures whether a resident’s significant other—a partner, close companion, or someone with a meaningful relationship—was involved in the assessment and goal-setting process. Involving the significant other ensures that the resident’s care plan is informed by the perspectives and insights of those who know them best.

Accurate documentation of the significant other’s involvement is essential for creating a care plan that truly reflects the resident’s wishes and needs.

Guidelines for Coding Q0110C

Coding Instructions:
To correctly code Item Q0110C, follow these steps:

1. Determine the Role of the Significant Other: Assess whether a significant other, such as a partner or close companion, was involved in the resident’s assessment and goal-setting process. This could include participating in care planning meetings, discussing the resident’s goals, or helping to make decisions about the resident’s care and discharge.
2. Select the Appropriate Response:
   • 1: Yes - Select this code if the significant other was involved in the assessment and goal-setting process.
   • 0: No - Select this code if the significant other was not involved.
3. Enter the Response in Item Q0110C: Record the selected response in Item Q0110C. Ensure that the resident’s care plan includes documentation of the significant other’s involvement and any decisions or input provided during the process.
4. Document the Role of the Significant Other: If a significant other was involved, provide additional documentation detailing their role, the decisions made, and how their input was incorporated into the resident’s care plan.

Example Scenario:
A resident who is planning for discharge to return home involves their long-term partner in the care planning process. The partner actively participates in discussions about the resident’s needs and goals for returning to the community, providing valuable input on what support will be needed at home. The MDS Coordinator documents the partner’s involvement in Item Q0110C by selecting code 1 ("Yes"). This ensures that the resident’s care plan reflects the partner’s contributions and that the discharge planning is aligned with the resident’s preferences.

Best Practices for Accurate Coding

Documentation:
Maintain thorough documentation of the significant other’s involvement in the assessment and goal-setting process. This should include notes on the significant other’s contributions and how their input was integrated into the care plan. This documentation supports the coding of Item Q0110C and ensures that the resident’s care plan aligns with their and their significant other’s wishes.

Communication:
Ensure effective communication between the care team, the resident, and the significant other. Clear communication is crucial for understanding the significant other’s insights and for ensuring that these are accurately reflected in the resident’s care plan.

Training:
Provide regular training to staff on the importance of involving significant others in the care planning process and how to document their participation accurately. Staff should understand the value of the significant other’s perspective in creating a comprehensive and person-centered care plan.

Conclusion

Summary:
MDS Item Q0110C is essential for documenting the involvement of a significant other in the assessment and goal-setting process for residents in long-term care. By correctly coding this item and ensuring clear documentation, healthcare professionals can support resident-centered care while maintaining compliance with CMS regulations. Following the guidelines and best practices outlined in this article will help ensure that the resident’s care plan reflects the insights and contributions of those closest to them.

Click here to see a detailed step-by-step on how to complete this item set 

Reference

CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. Refer to [Chapter 3, Page 3-16] for detailed guidelines on the CAA process and the role of significant others in assessment and goal participation.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item Q0110C: "Assessment and Goal Participation: Significant Other" was originally based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.