Step-by-Step Coding Guide for Item Set A1010A: Race - White

1. Review of Medical Records

• Objective: Accurately determine and document the resident’s race as "White."
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including admission forms, demographic information, and previous assessments.
  2. Identify Race Documentation: Look for documented instances where the resident’s race is specified, such as in demographic sections or initial assessments.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across various sources within the medical records.

2. Understanding Definitions

• Race - White: Refers to individuals having origins in any of the original peoples of Europe, the Middle East, or North Africa.
• Key Points:
  • This category includes people who identify as White, including those who identify with European, Middle Eastern, or North African ancestry.
  • Ensure that the race information is self-reported by the resident or their legal representative.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records if the resident has self-identified as White.
  2. Verify Documentation: Ensure that the race identification is clearly noted in the records.
  3. Code Appropriately: Enter the code for race as "White" in item set A1010A:
     • 1: Yes, the resident identifies as White.
     • 0: No, the resident does not identify as White.

4. Coding Tips

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

5. Documentation

• Required:
  • Admission Forms: Forms completed during the resident’s admission, where race is documented.
  • Demographic Information: Sections in the medical records that include demographic details.
  • Previous Assessments: Any previous assessments that have documented the resident’s race.
  • Resident Self-Report: Documentation confirming that the resident or their legal representative self-reported their race.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the resident’s self-identified race through multiple records.
• Incomplete Documentation: Make sure all relevant notes, admission forms, and assessments are included to support the race identification.
• Assumptions: Do not assume the resident’s race without proper documentation and verification; always rely on self-report.

7. Practical Application

• Example:
  • Resident Profile: John, a 78-year-old resident, has indicated on his admission form that he identifies as White.
  • Steps:
    1. Review Records: The nurse reviews John’s medical records, noting the demographic information on the admission form.
    2. Identify Race: It is confirmed through the admission form and previous assessments that John identifies as White.
    3. Document and Code: The nurse documents John’s race in the records and codes A1010A as "1".
  • Outcome: John’s race as White is accurately documented and coded, ensuring proper demographic data collection and compliance.

Please note that the information provided in this guide for MDS 3.0 Item set A1010A 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.