Q0400: Discharge Plan
Step-by-Step Coding Guide for Q0400: Discharge Plan
1. Review of Medical Records
- Objective: Carefully examine the resident's medical records for any documentation related to discharge planning. This includes physician orders, care plans, social service notes, and any interdisciplinary team notes.
- Key Documents to Review: Look for assessments that indicate the resident's potential for discharge, discussions regarding discharge planning, and any documented plans or referrals made as part of discharge preparation.
2. Understanding Definitions
- Discharge Plan: A coordinated plan developed by the care team in consultation with the resident and their family or representative, detailing the steps, services, and support needed for the resident to safely transition from the care facility to the next setting, whether it's home, another care facility, or a community-based setting.
3. Coding Instructions
For Q0400, you will likely be coding whether a discharge plan has been initiated, what components the plan includes, and whether specific tasks have been completed or are in progress.
4. Coding Tips
- Ensure all aspects of the discharge planning process are explored, including physical, medical, social, and environmental needs.
- Review the discharge planning documentation for completeness and accuracy before coding.
5. Documentation
- Document detailed notes on the discharge planning process, including who was involved (resident, family, care team), the goals of discharge, and any services or referrals arranged.
- Record any barriers to discharge identified and how they are being addressed.
6. Common Errors to Avoid
- Incomplete Documentation: Failing to document all elements of the discharge plan, including resident and family education, follow-up appointments, and any equipment or home modifications needed.
- Lack of Interdisciplinary Involvement: Discharge planning should involve a team approach. Ensure documentation reflects input from all relevant disciplines.
- Overlooking Resident and Family Input: The resident’s and their family's preferences and concerns must be considered and documented in the plan.
7. Practical Application
Example Scenario: A resident recovering from hip surgery has met their rehabilitation goals and is preparing to return home. The discharge plan includes home health services, outpatient physical therapy, a home safety evaluation, and arrangements for durable medical equipment.
- Documentation Needed: Include the discharge meeting summary, detailing the plan's components, participant's input, and any follow-up required.
- Coding: Based on the MDS item specifics, code to reflect that the discharge plan has been initiated and detail its components.
The Step-by-Step Coding Guide for item Q0400 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. Please note that 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.
