Step-by-Step Coding Guide for Item Set Q0550C: Information Source for Q0550A

This comprehensive guide aims to facilitate the accurate documentation and coding of the source of information regarding the reasking of a resident's preferences, as specified in Q0550C of the MDS 3.0.

1. Review of Medical Records

• Objective: To identify the source of information for the reasking of resident preferences.
• Key Points:
  • Carefully review the resident's care plans, progress notes, and any communication logs for documentation that indicates who provided the information for the reassessment of preferences noted in Q0550A.
  • Look for entries that detail discussions about preferences with the resident, their family, legal guardians, or other representatives, noting who initiated or provided key information during these discussions.

2. Understanding Definitions

• Objective: Clarify the meaning of "Information Source for Q0550A."
• Key Points:
  • This item identifies who provided the information when a resident's preferences were reassessed, helping to ensure that the process is resident-centered and accurately documented.

3. Coding Instructions

• Objective: Accurately code the source of information for the reasking of resident preferences.
• Key Points:
  • Code 1: If the resident directly provided the information during reassessment.
  • Code 2: If family members or significant others were the source of the updated information.
  • Code 3: If staff members initiated the reassessment and documented the resident’s responses.
  • Code 4: If information came from external sources, such as previous care providers or written directives.
  • Code 8: Use this code for any other sources of information not described above.

4. Coding Tips

• Cross-reference all available documentation to accurately determine the information source.
• Be mindful of the resident's current ability to communicate preferences and consider multiple sources of information where necessary.

5. Documentation

• Clearly document in the resident's medical record the source of the information when preferences were reassessed, including specific individuals involved and their relationship to the resident.
• Note the date and context of the reassessment to provide a clear timeline of when and how preferences were reviewed.

6. Common Errors to Avoid

• Overlooking or misdocumenting the source of information, leading to inaccuracies in the resident's care plan.
• Failing to acknowledge and document when multiple sources contribute to the reassessment of preferences.

7. Practical Application

• Scenario: During a routine care plan review, a nurse discusses with a resident their current preferences for meal times and activities. The resident expresses a change in preferences, which the nurse documents, including the resident as the source of information (Code 1). This documentation is essential for updating the care plan to reflect the resident’s current wishes.

The Step-by-Step Coding Guide for item Q0550C 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.