A1010K: Race: Native Hawaiian, Step-by-Step
Step-by-Step Coding Guide for Item Set A1010K: Race: Native Hawaiian
1. Review of Medical Records
- Objective: Gather accurate information regarding the resident’s racial identification as Native Hawaiian.
- Steps:
- Collect Information: Review the resident's comprehensive medical records, including admission forms, demographic information, and previous assessments.
- Identify Racial Identification: Look for documentation where the resident’s race is identified.
- Confirm Self-Identification: Verify that the racial identification as Native Hawaiian is self-reported by the resident or a family member.
2. Understanding Definitions
- Native Hawaiian: Refers to individuals having origins in any of the original peoples of Hawaii. This classification is based on self-identification by the resident or their family.
- Key Points:
- Self-Identification: The race of the resident should be based on their own identification or that of their family if the resident is unable to self-identify.
3. Coding Instructions
- Steps:
- Identify Race: Confirm the resident's identification as Native Hawaiian from the medical records.
- Verify Documentation: Ensure the racial identification as Native Hawaiian is documented appropriately.
- Code Appropriately: Code A1010K as "1" if the resident identifies as Native Hawaiian, and "0" if they do not.
4. Coding Tips
- Accurate Identification: Ensure the racial identification is correctly noted and self-reported.
- Consistent Terminology: Use consistent terminology when documenting and coding racial identification.
- Consult Records: If there is any uncertainty, consult with the resident or family members for clarification.
5. Documentation
- Required:
- Admission Forms: Include the resident's demographic information and self-identified race.
- Assessment Records: Document any assessments that include the resident’s racial identification.
- Verification Notes: Ensure there are notes confirming the racial identification is self-reported.
6. Common Errors to Avoid
- Misclassification: Ensure accurate classification by verifying the resident’s self-reported racial identification.
- Incomplete Documentation: Make sure all relevant records and notes are included.
- Assumptions: Do not assume the resident’s race without proper documentation and self-reporting.
7. Practical Application
- Example:
- Resident Profile: Lani, a 68-year-old resident, identifies as Native Hawaiian.
- Steps:
- Review Records: The nurse reviews Lani’s admission forms and demographic information, confirming her self-identification as Native Hawaiian.
- Confirm Self-Identification: It is verified that Lani self-identified as Native Hawaiian during the admission process.
- Document and Code: The nurse documents the racial identification in Lani’s records and codes A1010K as "1".
- Outcome: Lani’s identification as Native Hawaiian is accurately documented and coded, ensuring proper record-keeping and compliance.
Please note that the information provided in this guide for MDS 3.0 Item set A1010K 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.
