A1010B: Race -Black or African American, Step-by-Step
Step-by-Step Coding Guide for A1010B: Race – "Black or African American"
1. Review of Medical Records
Objective: Assess and document the resident's race based on self-identification as Black or African American.
Actions:
- Review demographic information in the resident's medical records.
- Directly ask the resident about their race using standard terminology such as "Black or African American."
- If the resident is unable to respond, consult a family member, caregiver, or legally authorized representative.
2. Understanding Definitions
A1010B: Black or African American refers to a person having origins in any of the Black racial groups of Africa. It includes people from various African and Afro-Caribbean backgrounds, such as those identifying as Haitian.
Example Scenario:
- Resident A: The resident identifies as African American. This would be coded as A1010B: Black or African American.
3. Coding Instructions
Step-by-Step:
- Step 1: Ask the resident to identify their race.
- Step 2: If the resident identifies as Black or African American, select A1010B.
- Step 3: If the resident cannot respond, ask family members or a legal representative. If they provide the answer, record A1010B and also mark X for the resident being unable to respond.
- Step 4: If the resident declines to answer, code Y: Resident declines to respond.
4. Coding Tips
- Self-Identification: Always base race coding on the resident's own identification.
- Multiple Responses: A resident can identify with multiple racial categories. If they identify as Black or African American, check A1010B even if other races are also selected.
- Documentation Sources: Only use family or medical records if the resident is unable to respond and no one else can provide the answer.
5. Documentation
Objective: Accurately record the resident’s race to support demographic tracking and personalized care.
Actions:
- Clearly document the resident’s self-reported race as Black or African American in the care plan.
- If the resident is unable to respond, document the input from family members or legally authorized representatives.
6. Common Errors to Avoid
- Assuming Race: Avoid making assumptions based on the resident's appearance or other factors without asking them directly.
- Incomplete Records: Ensure all necessary documentation is completed, especially when family members provide the response on behalf of the resident.
7. Practical Application
Example 1:
A resident identifies as Black and also mentions a Haitian background. This would be coded as A1010B: Black or African American.
Example 2:
A resident is unable to respond due to cognitive impairment, and their child confirms they are African American. Code A1010B and X: Resident unable to respond.
Please note that the information provided in this guide for MDS 3.0 Item set A1010B 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.
