Step-by-Step Coding Guide for Q0110B. Asmt and Goal Participation: Family

1. Review of Medical Records

• Objective: Collect comprehensive information on family or representative participation in assessments and goal setting for the resident.
• Key Points:
  • Examine the resident's file for documentation of family meetings, discussions about care preferences and goals, and any written communication from the family or representative.
  • Note the presence and outcomes of family care planning meetings or interdisciplinary team meetings where the family contributed to the discussion.

2. Understanding Definitions

• Objective: Clarify what constitutes family participation in assessments and goal setting.
• Key Points:
  • Family Participation: Refers to the involvement of family members or representatives in discussing, planning, and setting goals for the resident's care.
  • Goal Setting: A collaborative process that includes the family in establishing objectives for the resident’s care and quality of life improvements.

3. Coding Instructions

• Objective: Ensure accurate recording of the family's level of participation.
• Key Points:
  • Code 0: If the family did not participate in the assessment or goal setting.
  • Code 1: If the family participated in some but not all discussions about assessment and goal setting.
  • Code 2: If the family fully participated in both assessment and goal setting.
• Example: If a family member discusses the resident's dietary preferences and actively engages in setting a nutrition-related goal, this would indicate full participation.

4. Coding Tips

• Verify family participation through various sources, such as meeting notes and care plan documents.
• Acknowledge different forms of family involvement, including remote participation via phone or video calls.

5. Documentation

• Clearly document the extent of family participation in the resident's medical record, including details of the discussions and decisions made.
• Record any barriers to family participation and efforts made to facilitate involvement.

6. Common Errors to Avoid

• Not formally inviting family members to participate in care planning meetings.
• Overlooking the documentation of family input and preferences.
• Assuming non-response or absence indicates lack of interest in participation.

7. Practical Application

• Scenario: The family of a resident with dementia participates in a care planning meeting to discuss behavioral management strategies. They share insights about the resident's life history, preferences, and triggers. The interdisciplinary team and the family collaboratively develop a personalized care approach, which is documented in the care plan.

The Step-by-Step Coding Guide for item Q0110B 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.