Step-by-Step Coding Guide for Q0110C. Asmt and Goal Participation: Significant Other

1. Review of Medical Records

• Objective: To collect detailed information on the participation of a significant other in the resident's assessment and goal setting.
• Key Points:
  • Carefully review the resident's medical records for notes on discussions, care planning meetings, and any documented preferences or input from a significant other.
  • Look for documented evidence of significant other’s involvement in setting goals or making decisions about the resident's care plan.

2. Understanding Definitions

• Objective: Clarify the role and involvement of a significant other in the care planning process.
• Key Points:
  • Significant Other Participation: Involves the active engagement of the resident's significant other in discussions, planning, and goal setting for care and treatment.
  • Goal Setting: A cooperative process that includes the significant other in establishing care objectives that aim to enhance the resident's well-being.

3. Coding Instructions

• Objective: To accurately record the level of participation by the significant other.
• Key Points:
  • Code 0: If the significant other did not participate in the assessment or goal setting.
  • Code 1: If the significant other participated in some but not all aspects of assessment and goal setting.
  • Code 2: If the significant other fully participated in both the assessment and goal setting.
• Example: If a significant other provides detailed preferences regarding the resident's daily routines and collaborates on setting a goal for improving daily life, this is an example of full participation.

4. Coding Tips

• Ensure that any form of participation by the significant other, whether in-person, via phone, or through written communication, is recognized and accurately coded.
• Engage in active and open communication with the significant other to accurately understand their level of involvement.

5. Documentation

• Precisely document the significant other’s contributions, preferences expressed, and any goals set during the care planning process in the resident's medical record.
• Include details on the manner of the significant other’s participation (e.g., in-person, electronically).

6. Common Errors to Avoid

• Failing to acknowledge or document the participation of a significant other due to communication barriers or logistical issues.
• Assuming that the absence of a significant other from meetings equates to a lack of interest or participation in care planning.

7. Practical Application

• Scenario: A significant other provides critical insight into the resident's likes and dislikes, past life experiences, and health care preferences during a care planning session. This information leads to a tailored care plan aimed at enhancing the resident's quality of life, with specific goals for social engagement and activity preferences.

The Step-by-Step Coding Guide for item Q0110C 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.