Step-by-Step Coding Guide for Item Set A1010I: Race - Vietnamese

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s racial identification.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including admission forms, demographic information, and any previous assessments.
  2. Identify Racial Identification: Look for documented instances where the resident’s race is identified, specifically noting if they are listed as Vietnamese.
  3. Confirm Details: Verify the resident’s racial identification through consistent documentation in multiple sources.

2. Understanding Definitions

• Race - Vietnamese: Refers to individuals who identify as part of the Vietnamese ethnic group, typically originating from the country of Vietnam.
• Key Points:
  • Ensure that the racial identification aligns with the resident’s self-reported or officially documented ethnicity.
  • Recognize that this identification is based on the resident’s own declaration or verified demographic information.

3. Coding Instructions

• Steps:
  1. Identify Resident’s Race: Confirm that the resident identifies as Vietnamese from the medical records.
  2. Verify Documentation: Ensure the racial identification is clearly documented and consistent across all records.
  3. Code Appropriately: Code A1010I as "1" if the resident identifies as Vietnamese, and "0" if they do not.

4. Coding Tips

• Accurate Identification: Ensure the resident’s racial identification as Vietnamese is self-reported or documented accurately in their records.
• Consistent Terminology: Use consistent terminology when documenting and coding the resident’s race.
• Respect Resident’s Identification: Always use the resident’s self-identified race when coding.

5. Documentation

• Required:
  • Admission Forms: Ensure the resident’s racial identification is recorded accurately on admission forms.
  • Demographic Information: Include copies of demographic information that show the resident’s race.
  • Assessment Records: Document the resident’s racial identification accurately in all assessment records.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the resident’s race through multiple sources.
• Incomplete Documentation: Make sure all relevant details about the resident’s racial identification are thoroughly documented.
• Assumptions: Do not assume the resident’s race without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: Mai, a 75-year-old resident, identifies as Vietnamese.
  • Steps:
    1. Review Records: The nurse reviews Mai’s medical records, including admission forms and demographic information.
    2. Identify Race: It is confirmed that Mai identifies as Vietnamese and this is documented in her records.
    3. Document and Code: The nurse documents Mai’s racial identification and codes A1010I as "1".
  • Outcome: Mai’s racial identification as Vietnamese is accurately documented and coded, ensuring proper demographic records and care planning.

Please note that the information provided in this guide for MDS 3.0 Item set A1010I 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.