Step-by-step Coding Guide for Q0110: Participation in Assessment and Goal Setting   

1. Review of Medical Records

• Objective: Thoroughly review the resident’s medical records to identify documentation that reflects the resident's involvement in the assessment process and goal setting. This includes care plans, notes from care planning meetings, and any assessments that indicate resident preferences and goals.
• Key Documents to Review: Look for notes from interdisciplinary team meetings, social work assessments, therapy assessments, and nursing care plans.

2. Understanding Definitions

• Participation in Assessment: Involves the resident's active involvement in discussing their care needs, preferences, strengths, and goals.
• Goal Setting: The process of identifying desired outcomes or objectives the resident hopes to achieve through their care plan.

3. Coding Instructions

For Q0110, code based on the resident's reported or observed involvement in their assessment and the goal-setting process:

• A. Resident participated in the assessment
• B. Resident participated in setting goals

4. Coding Tips

• Ensure coding reflects direct participation or input from the resident, not just the care team's assessment of needs or goals on the resident's behalf.
• Consider any communication aids or methods used to facilitate the resident's involvement if they have speech or cognitive impairments.

5. Documentation

• Document instances where the resident provided input on their care preferences, goals, or participated in discussions about their care plan.
• Include notes from meetings or assessments that specifically mention the resident's contributions or responses.

6. Common Errors to Avoid

• Overlooking Resident Input: Failing to document or acknowledge when a resident has expressed preferences or goals, even if they are non-verbal or communicate through gestures.
• Assuming Participation: Assuming participation without direct evidence or documentation of the resident's involvement in discussions or goal-setting.

7. Practical Application

Example Scenario: A resident with post-stroke rehabilitation needs is asked about their goals for recovery. They express a desire to improve mobility to return to gardening. The care team documents this goal and discusses the steps and therapies needed to work toward this goal.

• Documentation Needed: Include detailed notes on the resident's expressed goal of returning to gardening, the specific therapies chosen to address mobility, and any modifications or accommodations discussed.
• Coding: Reflect the resident’s active participation in setting this goal by appropriately coding both the participation in assessment and in goal setting.

The Step-by-Step Coding Guide for item Q0110 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.