Step-by-Step Coding Guide for Item Set Q0110D: Assessment and Goal Participation: Legal Guardian

1. Review of Medical Records

• Objective: To compile detailed information about the legal guardian's involvement in the resident's assessment and goal-setting process.
• Key Points:
  • Thoroughly review the resident’s medical records for documentation indicating the legal guardian's input, including care planning meetings, documented preferences, and decisions made by the guardian.
  • Identify documentation of any communication with the legal guardian that reflects their involvement in care planning.

2. Understanding Definitions

• Objective: Clarify the role and expected involvement of a legal guardian in the care planning process.
• Key Points:
  • Legal Guardian Participation: Refers to the involvement of a resident’s legally appointed guardian in discussions, planning, and decision-making for care and treatment.
  • Goal Setting: A collaborative process that includes the legal guardian in setting objectives to improve the resident's quality of life and care outcomes.

3. Coding Instructions

• Objective: Accurately reflect the legal guardian’s level of participation.
• Key Points:
  • Code 0: If the legal guardian did not participate in the assessment or goal setting.
  • Code 1: If the legal guardian participated in some but not all aspects.
  • Code 2: If the legal guardian fully participated in both the assessment and goal setting.
• Example: A legal guardian who actively engages in discussions about the resident's healthcare needs and collaboratively sets goals with the care team would be coded as fully participating.

4. Coding Tips

• Recognize all forms of participation by the legal guardian, including indirect communication or written correspondence, and ensure it is accurately coded.
• Regularly update and review the legal guardian's contact information to facilitate ongoing involvement.

5. Documentation

• Clearly document the legal guardian’s participation in the resident's medical record, noting specific contributions and decisions made.
• Record any barriers to participation faced by the legal guardian and efforts made to involve them in the care planning process.

6. Common Errors to Avoid

• Overlooking or not documenting the legal guardian’s contributions and decisions due to communication challenges.
• Failing to adequately involve the legal guardian in the care planning process or not providing them with necessary information for informed decision-making.

7. Practical Application

• Scenario: During a care planning meeting, a legal guardian provides essential information about the resident's preferences for end-of-life care. This leads to the development of an advanced care plan that aligns with the resident's wishes, clearly documented with the guardian's involvement and approval.

The Step-by-Step Coding Guide for item Q0110D 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.