Step-by-Step Coding Guide for Item Set A1005Y: Ethnicity: Resident Declines to Respond

1. Review of Medical Records

• Objective: To confirm whether the resident has chosen not to disclose their ethnicity during the data collection process.
• Process:
  • Review the resident’s admission paperwork and initial assessments to see if there is a record of the resident declining to state their ethnicity.
  • Examine social work and nursing notes for any documented conversations where ethnicity may have been discussed and the resident’s preference for non-disclosure noted.
  • Consult with staff members who conducted the interviews or assessments to gather insights into the resident's response regarding their ethnicity.

2. Understanding Definitions

• Declines to Respond: Indicates that when asked about their ethnicity, the resident explicitly chose not to provide this information, as opposed to being unable to respond due to cognitive or communicative reasons.

3. Coding Instructions

• Code A1005Y:
  • 0: No, the resident did not decline to respond about their ethnicity.
  • 1: Yes, the resident declined to respond about their ethnicity.
• Example: If during the intake interview, the resident was asked about their ethnicity and they verbally refused to provide this information, code A1005Y as '1'.

4. Coding Tips

• Ensure that the resident’s response (or lack thereof) is due to a conscious decision to decline rather than an oversight or misunderstanding during the data collection.
• Reassess if necessary, especially if the initial refusal may have been influenced by stress or confusion during the admission process.

5. Documentation

• Required Documentation:
  • A clear notation in the resident’s file indicating that they were asked about their ethnicity and that they chose not to disclose this information.
  • Documentation should include the date, setting, and context in which the question was asked to ensure it was a deliberate refusal.
• Documentation should be precise and respect the resident’s right to privacy, ensuring that the decision to decline is respected and recorded without bias.

6. Common Errors to Avoid

• Misinterpreting a resident’s non-response due to communication barriers or cognitive impairments as a decline to respond.
• Failing to document the resident's decision to decline thoroughly, leading to potential confusion or errors in demographic data reporting.
• Assuming the resident’s decline without direct confirmation from the resident—ensure there is an explicit declaration of their choice.

7. Practical Application

• Scenario: During the initial assessment process, a resident was asked to specify their ethnicity for demographic purposes. The resident clearly stated they prefer not to disclose that information. This interaction was noted by the social worker conducting the assessment and was recorded in the resident’s social service file with a note explaining the resident’s right to decline this disclosure. The coding for A1005Y was subsequently set as '1', reflecting the resident’s decision.

Please note that the information provided in this guide for MDS 3.0 Item set A1005Y 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.