Step-by-Step Coding Guide for Item Set Q0110Z: Assessment and Goal Participation: None of the Above

1. Review of Medical Records

• Objective: To confirm the absence of participation by residents, family, significant others, legal guardians, or other legally authorized representatives in the assessment and goal-setting process.
• Key Points:
  • Thoroughly examine the resident's care and medical records to search for any documented evidence of participation in care planning by the resident or their representatives.
  • Check for any notes or documentation that might indicate attempts to involve these parties in care planning discussions or goal setting.

2. Understanding Definitions

• Objective: Clarify what is meant by "None of the above" in the context of assessment and goal participation.
• Key Points:
  • None of the Above: Indicates that none of the previously listed participants (resident, family, significant others, legal guardians, or other legally authorized representatives) were involved in the assessment or goal-setting process.

3. Coding Instructions

• Objective: Provide clear guidance on when and how to code for "None of the above."
• Key Points:
  • Code Z: If after thorough review, there is no documented participation from the resident, their family, significant others, legal guardians, or other legally authorized representatives in the care planning process.

4. Coding Tips

• Verify that all possible avenues for participant involvement have been explored and documented before selecting this code.
• Ensure documentation reflects attempts made to involve the resident or their representatives in the care planning process.

5. Documentation

• Document the lack of participation and reasons if known, including any barriers to participation or unsuccessful attempts to involve the resident or their representatives.
• Include a plan for future engagement attempts or strategies to involve the resident or their representatives in care planning.

6. Common Errors to Avoid

• Incorrectly coding this item due to incomplete review of care planning documentation or failure to document attempts to involve the resident or their representatives.
• Assuming lack of physical presence at care planning meetings equates to non-participation without considering other forms of involvement.

7. Practical Application

• Scenario: A care team exhausts all efforts to involve a resident and their family in care planning, but due to the resident's cognitive limitations and the family's lack of response, no participation is recorded. The team documents these efforts and the absence of participation, coding Q0110Z appropriately while planning strategies for future engagement.

The Step-by-Step Coding Guide for item Q0110Z 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.