Coding Section Q of the MDS, Participation and Goal Setting

Posted by LTCS on June 6, 2013

Home Health Care Nurse and Home Health Nursing Care PlansThe intent of section Q is to record the participation of the resident, family and/or significant others in the assessment, and to identify the resident’s long term and over-all goals. 

Interdisciplinary team members should engage the resident during the assessment in order to determine the resident’s expectations and perspective, and ask the resident to consider his or her current clinical status, expectations regarding improvement or worsening, and social supports. 

If goals have not already been stated directly by the resident and documented since admission, ask the resident directly about what his or her expectation is regarding the outcome of this nursing home admission and expectations about returning to the community. 

Q Participation in Assessment and Goal Setting