Step-by-Step Coding Guide for Item Set Q0490: Resident's Preference to Avoid Being Asked

1. Review of Medical Records

• Objective: Accurately determine and document the resident's preference to avoid being asked about certain topics or participating in specific activities.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including care plans, social work notes, psychiatric evaluations, and previous assessments.
  2. Identify Documentation of Preferences: Look for documented instances where the resident has expressed a preference to avoid being asked about certain subjects or activities.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across various sources within the medical records.

2. Understanding Definitions

• Resident's Preference to Avoid Being Asked: Indicates the resident's desire to avoid discussions or inquiries about specific topics or to not participate in certain activities.
• Key Points:
  • Preferences can be related to personal, cultural, religious, or emotional reasons.
  • Respecting these preferences is important for resident-centered care and maintaining the resident’s dignity and comfort.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records if the resident has expressed a preference to avoid being asked about certain topics or activities.
  2. Verify Documentation: Ensure that the resident's preference is clearly noted in the records.
  3. Code Appropriately: Enter the code for the resident’s preference to avoid being asked in item set Q0490:
     • 1: Yes, the resident has expressed a preference to avoid being asked.
     • 0: No, the resident has not expressed a preference to avoid being asked.

4. Coding Tips

• Accurate Identification: Ensure the resident’s preference is correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the resident’s preference.
• Clarify with the Resident: If there is any uncertainty, clarify with the resident or their legal representative to ensure accurate coding.

5. Documentation

• Required:
  • Care Plans: Detailed care plans that document the resident’s preferences, including any topics or activities they wish to avoid.
  • Social Work Notes: Notes from social workers detailing conversations with the resident about their preferences.
  • Psychiatric Evaluations: Evaluations from psychiatrists or psychologists that include the resident’s expressed preferences.
  • Previous Assessments: Any previous assessments that have documented the resident’s preference to avoid being asked about certain subjects or activities.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the resident’s preference through multiple records and notes.
• Incomplete Documentation: Make sure all relevant care plans, social work notes, and psychiatric evaluations are included to support the resident’s preference.
• Assumptions: Do not assume the resident’s preference without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Resident Profile: Jane, an 80-year-old resident, has expressed a preference to avoid discussing her past military service.
  • Steps:
    1. Review Records: The nurse reviews Jane’s medical records, noting the social work notes and care plans documenting her preference to avoid discussing her military service.
    2. Identify Preference: It is confirmed through the documentation that Jane has expressed this preference.
    3. Document and Code: The nurse documents Jane’s preference in her records and codes Q0490 as "1".
  • Outcome: Jane’s preference to avoid discussing her military service is accurately documented and coded, ensuring that her preference is respected in future interactions.

Please note that the information provided in this guide for MDS 3.0 Item set Q0490 was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.