Step-by-Step Coding Guide for Item Set Q0110A: Assessment and Goal Participation - Resident

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s participation in assessments and goal setting.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including care plans, progress notes, and previous assessments.
  2. Identify Participation: Look for documented instances where the resident participated in assessments and goal-setting discussions.
  3. Confirm Details: Verify the consistency of the resident’s participation through various sources within the medical records.

2. Understanding Definitions

• Assessment Participation: Refers to the resident’s involvement in the assessment process, including providing input and feedback.
• Goal Participation: Refers to the resident’s involvement in setting goals related to their care, treatment, and outcomes.

3. Coding Instructions

• Steps:
  1. Identify Participation: Confirm the resident’s participation in assessments and goal-setting based on the review of medical records.
  2. Verify Documentation: Ensure the resident’s participation is well-documented in care plans, assessment records, and progress notes.
  3. Code Appropriately: Code Q0110A as "1" if the resident participated in the assessment and goal-setting process, and "0" if they did not.

4. Coding Tips

• Accurate Identification: Ensure the resident’s participation is clearly documented and reflects their active involvement.
• Consistent Terminology: Use consistent terminology when documenting and coding the resident’s participation.
• Consult Care Team: If there is any uncertainty, consult with the resident’s care team, including nurses and care coordinators, for clarification.

5. Documentation

• Required:
  • Care Plans: Document the resident’s involvement in creating and updating care plans.
  • Assessment Records: Include records of assessments where the resident’s input and feedback are documented.
  • Progress Notes: Document any relevant observations about the resident’s participation in goal-setting and assessment discussions.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the resident’s participation through multiple sources.
• Incomplete Documentation: Make sure all relevant details about the resident’s participation are thoroughly documented.
• Assumptions: Do not assume the resident’s participation without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: Sarah, a 75-year-old resident, actively participated in her care plan meetings and provided feedback during assessments.
  • Steps:
    1. Review Records: The nurse reviews Sarah’s medical records, including care plans and progress notes that document her participation.
    2. Identify Participation: It is confirmed that Sarah actively participated in setting goals and providing input during assessments.
    3. Document and Code: The nurse documents Sarah’s participation and codes Q0110A as "1".
  • Outcome: Sarah’s active participation in the assessment and goal-setting process is accurately documented and coded, ensuring proper follow-up and care planning.

Please note that the information provided in this guide for MDS 3.0 Item set Q0110A was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. 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.