A1010H: Race - "Korean", Step-by-Step
Step-by-Step Coding Guide for A1010H: Race – "Korean"
1. Review of Medical Records
Objective: Document whether the resident identifies as Korean under the race section of the MDS assessment.
Actions:
- Review the resident's medical and admission records to gather demographic information.
- Directly ask the resident whether they identify as Korean, ensuring their response reflects their racial self-identification.
- If the resident is unable to respond, consult with family members or a legally authorized representative for accurate documentation.
2. Understanding Definitions
A1010H: Korean refers to a person having origins in the Korean peninsula or from a Korean ethnic background. This falls under the Asian category as per the MDS 3.0 standards.
Example Scenario:
- Resident A: A resident identifies as Korean, having both parents from South Korea. This would be coded as A1010H: Korean.
3. Coding Instructions
Step-by-Step:
- Step 1: Ask the resident if they identify as Korean.
- Step 2: If the resident affirms, check the box for A1010H.
- Step 3: If the resident cannot respond, consult a family member or legally authorized representative to provide this information.
- Step 4: If no one can confirm the resident’s race, document X: Resident unable to respond.
4. Coding Tips
- Self-Identification is Key: Ensure that the race is based on how the resident identifies, rather than assumptions made from appearance or documentation.
- Multiple Selections: If the resident identifies with more than one race, select all that apply, including A1010H for Korean if applicable.
5. Documentation
Objective: Ensure the resident’s racial background is accurately recorded to contribute to demographic data and personalized care.
Actions:
- Clearly record the resident's identification as Korean and include supporting notes if family members or representatives provided this information.
- If the resident is unable to respond, indicate their inability and document responses provided by family or representatives.
6. Common Errors to Avoid
- Assuming Race: Never assume a resident’s race based on physical characteristics. Always ask for their self-identification or consult reliable sources.
- Incomplete Documentation: Ensure that all racial categories the resident identifies with are marked and clearly documented.
7. Practical Application
Example 1:
A resident whose family reports Korean descent and cultural background would be coded as A1010H: Korean.
Example 2:
A resident with a cognitive impairment is unable to respond, and no family is available. Code X: Resident unable to respond.
Please note that the information provided in this guide for MDS 3.0 Item set A1010H 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.
