Step-by-Step Coding Guide for Q0110A. Asmt and Goal Participation: Resident

1. Review of Medical Records

• Objective: To gather comprehensive information about the resident's participation in assessment and goal setting.
• Key Points:
  • Examine medical records, including care plans, assessments, and notes from interdisciplinary team meetings that document the resident's level of participation.
  • Look for documented resident preferences, goals, and any prior discussions about their care and treatment plans.

2. Understanding Definitions

• Objective: To clarify the meaning of resident participation in assessment and goal setting.
• Key Points:
  • Resident Participation: Involves the resident in discussions about their care, preferences, and goals. It's essential for person-centered care.
  • Goal Setting: Collaborative process between the resident (and possibly their family) and healthcare providers to establish objectives for improving quality of life.

3. Coding Instructions

• Objective: To accurately record the resident's level of participation.
• Key Points:
  • Code 0: If the resident did not participate in assessment or goal setting.
  • Code 1: If the resident participated in some but not all aspects.
  • Code 2: If the resident fully participated in both assessment and goal setting.
• Example: A resident who expresses their preferences for daily activities and participates in setting a goal for improved mobility would be coded as fully participating.

4. Coding Tips

• Ensure accuracy by corroborating information from multiple sources (e.g., nursing notes, therapy assessments).
• Consider the resident's cognitive and physical ability to participate; adaptations may be necessary.

5. Documentation

• Document discussions, resident preferences, and goals in the care plan and medical record.
• Include details of the resident's participation level and any barriers encountered.

6. Common Errors to Avoid

• Failing to engage the resident in the conversation.
• Overlooking the resident's communication style or preferences.
• Not documenting the resident's participation accurately.

7. Practical Application

• Scenario: A resident with limited mobility expresses a desire to walk to the dining room for meals. The care team discusses various interventions, including physical therapy, to support this goal. The resident's participation in setting this goal is documented, including their expressed preferences and the agreed-upon plan.

The Step-by-Step Coding Guide for item Q0110A 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.