Step-by-Step Coding Guide for Item Set A1010C: Race: American Indian or Alaska Native

1. Review of Medical Records

• Objective: To accurately gather comprehensive information about the resident’s racial background.
• Steps:
  1. Collect Information: Review the resident's medical records, admission forms, and any previous assessments.
  2. Resident and Family Interviews: Conduct interviews with the resident and family members to confirm racial background.
  3. Historical Data: Look for any documentation from previous healthcare providers or facilities that indicates the resident’s race.

2. Understanding Definitions

• American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.
• Key Points:
  • Tribal Affiliation: Verification of tribal affiliation can include tribal identification cards or other documentation from a recognized tribe.
  • Community Attachment: Evidence of community involvement or attachment, such as participation in cultural events or recognition by the community.

3. Coding Instructions

• Steps:
  1. Initial Identification: Identify if the resident self-identifies as American Indian or Alaska Native.
  2. Documentation: Ensure that the identification is documented in the resident's record.
  3. Code Appropriately: In the MDS, code A1010C as "1" for American Indian or Alaska Native if the resident meets the criteria.

4. Coding Tips

• Consistency: Ensure that the race is consistently documented across all forms and records.
• Verification: Confirm with multiple sources if possible, including interviews and documents.
• Respect Privacy: Handle all personal and racial information sensitively and confidentially.

5. Documentation

• Required Documentation:
  • Admission Forms: Ensure the resident’s racial background is correctly filled out in the admission forms.
  • Medical Records: Include documentation of the resident’s race in their medical history.
  • Verification Documents: Attach any verification documents, such as tribal ID cards or letters from tribal organizations.

6. Common Errors to Avoid

• Misidentification: Avoid coding based on assumptions or incomplete information.
• Inconsistent Documentation: Ensure that the resident’s racial background is recorded consistently across all documentation.
• Lack of Verification: Always verify the information with reliable sources.

7. Practical Application

• Case Study:
  • Resident Profile: A new resident, identified as John Doe, moves into the facility. John has indicated that he is of American Indian heritage.
  • Steps Taken:
    1. Review Records: The admission nurse reviews John’s previous medical records and finds documentation of his affiliation with a recognized tribe.
    2. Interview: The nurse conducts an interview with John and his family to confirm his tribal affiliation and community involvement.
    3. Documentation: The nurse records this information accurately in John’s medical records and ensures that his race is coded as American Indian or Alaska Native in the MDS.
  • Outcome: John’s racial background is correctly identified and coded, ensuring accurate and respectful documentation of his identity.

Illustrations and Examples

1. Flowchart of the Coding Process:

   • Start with reviewing medical records.
   • Conduct resident and family interviews.
   • Verify with documentation.
   • Code in MDS accurately.

2. Sample Interview Questions:

   • "Can you confirm your tribal affiliation?"
   • "Do you have any documentation from your tribe?"
   • "Are there any community events or activities you are involved in?"

Please note that the information provided in this guide for MDS 3.0 Item set A1010C 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.