Step-by-Step Coding Guide for Item Set Q0310A: Resident's Overall Goal for Discharge

1. Review of Medical Records

• Objective: To gather comprehensive information about the resident's expressed or documented discharge goals.
• Key Points:
  • Thoroughly review the resident's care plan, progress notes, social services documentation, and any advanced directives for mentions of discharge goals or preferences.
  • Look for documented discussions with the resident, their family, or representatives regarding discharge planning and goals.

2. Understanding Definitions

• Objective: Clarify the meaning of "Resident's Overall Goal for Discharge."
• Key Points:
  • This item captures the resident’s primary objective regarding discharge from the facility, whether it's to return home, transfer to another facility, or another specified goal.

3. Coding Instructions

• Objective: Provide clear guidance on how to code the resident’s discharge goal.
• Key Points:
  • Code 0: If the resident's goal is to remain in the facility long-term without plans for discharge.
  • Code 1: If the resident hopes to discharge to the community (e.g., home, assisted living).
  • Code 8: For situations where the resident's discharge goal is uncertain or has not been discussed.
  • Code 9: If the discharge goal is not applicable due to the resident's condition or prognosis.

4. Coding Tips

• Ensure that any coding decision is supported by comprehensive documentation in the resident's medical records.
• Regularly update the coding as the resident's goals or condition changes over time.

5. Documentation

• Document all discussions regarding discharge planning with the resident and/or their representatives, including specific goals, preferences, and any changes over time.
• Clearly note the rationale for the selected discharge goal code based on these discussions and planning sessions.

6. Common Errors to Avoid

• Failing to update the discharge goal as the resident's condition, preferences, or circumstances change.
• Overlooking or inadequately documenting conversations with the resident or their representatives about discharge planning.

7. Practical Application

• Scenario: A resident initially expresses a desire to return home after rehabilitation but later decides to move to an assisted living facility due to concerns about living independently. This change is discussed in a care planning meeting, documented in the medical record, and the resident's discharge goal is updated accordingly in the MDS.

The Step-by-Step Coding Guide for item Q0310A 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.