Q0310B. Information Source for Q310A, Step-by-Step
Step-by-Step Coding Guide for Item Set Q0310B: Information Source for Q0310A
This guide provides a structured approach to accurately coding the source of information for a resident's overall goal for discharge, as outlined in Q0310A of the MDS 3.0.
1. Review of Medical Records
- Objective: To identify and verify the source(s) of information regarding the resident's discharge goal.
- Key Points:
- Carefully review the resident's medical and care planning records for notes indicating who provided the information about the discharge goal (resident, family, legal guardian, etc.).
- Pay attention to progress notes, social work assessments, and care planning meeting minutes where discharge planning was discussed.
2. Understanding Definitions
- Objective: Clarify what is meant by "Information Source for Q0310A."
- Key Points:
- Information Source: Refers to the individual(s) or documentation that provided insights into the resident's overall goal for discharge.
3. Coding Instructions
- Objective: Accurately code the source of information for the resident's discharge goal.
- Key Points:
- Code 1: If the information was provided directly by the resident.
- Code 2: If family members or significant others provided the information.
- Code 3: If a legal guardian or legally authorized representative provided the information.
- Code 4: If the information source was documentation or care plans from another facility or provider.
- Code 5: If staff members, based on their knowledge of the resident, provided the information.
- Code 8: For any other information source not covered by the previous codes.
4. Coding Tips
- Cross-verify the information source with multiple sections of the resident's records to ensure accuracy.
- Document any direct quotations or paraphrased statements from the information source that clarify the resident's discharge goal.
5. Documentation
- Clearly note in the resident's medical record the specific source of information for the discharge goal, including names and roles if appropriate.
- Document the date(s) on which the information was provided and any relevant discussions or meetings.
6. Common Errors to Avoid
- Coding an information source based on assumption rather than documented evidence.
- Failing to update the information source if new information becomes available or if the discharge goal changes.
7. Practical Application
- Scenario: During a care planning meeting, a resident expresses a desire to return home after rehabilitation. This goal and the resident's statement are documented in the meeting minutes. The source of information for the discharge goal is coded as directly from the resident (Code 1).
The Step-by-Step Coding Guide for item Q0310B 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.
