Step-by-Step Coding Guide for Item Set Q0110E: Assessment and Goal Participation: Other Legally Authorized Representative

1. Review of Medical Records

• Objective: Gather comprehensive details on the participation of other legally authorized representatives in the resident's care planning.
• Key Points:
  • Examine the resident's medical and care planning records for notes, documented preferences, decisions, and input from the legally authorized representative.
  • Look for evidence of communication or meetings that include the representative’s contributions towards the resident’s care and goals.

2. Understanding Definitions

• Objective: Clarify the involvement expected from other legally authorized representatives in care planning.
• Key Points:
  • Legally Authorized Representative Participation: Involves the engagement of an individual, appointed through legal means other than guardianship, in discussions, planning, and decision-making for the resident’s care.
  • Goal Setting: A joint effort that encompasses the legally authorized representative in setting care and quality of life objectives for the resident.

3. Coding Instructions

• Objective: Ensure the legally authorized representative’s participation level is accurately recorded.
• Key Points:
  • Code 0: If the representative did not participate in the assessment or goal setting.
  • Code 1: If the representative was involved in some aspects of assessment and goal setting.
  • Code 2: If the representative fully participated in both assessment and goal setting.
• Example: A representative who communicates the resident's personal healthcare preferences for care planning and participates in establishing specific care goals would be considered as fully participating.

4. Coding Tips

• Account for all participation forms, including indirect methods like emails or proxy decision-making, ensuring comprehensive coding.
• Maintain open lines of communication to facilitate the representative’s ongoing involvement.

5. Documentation

• Document the representative’s contributions, preferences, and decisions in the care planning process within the resident's medical record.
• Note any participation barriers and the measures taken to facilitate involvement.

6. Common Errors to Avoid

• Neglecting to document the participation of the legally authorized representative due to logistical or communication issues.
• Incorrectly assuming that lack of physical presence indicates non-participation.

7. Practical Application

• Scenario: A legally authorized representative provides crucial insights during a care plan meeting regarding the resident's dietary restrictions and social preferences. This information guides the development of a personalized care plan, enhancing the resident's satisfaction and quality of life.

The Step-by-Step Coding Guide for item Q0110E 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.