Step-by-Step Coding Guide for Item Set A1010M: Race - Samoan

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s race to determine if they identify as Samoan.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including admission forms, demographic information, social work assessments, and previous assessments.
  2. Identify Ethnicity Documentation: Look for documented instances where the resident’s race is specified as Samoan.
  3. Confirm Details: Verify the consistency of the race documentation through various sources within the medical records.

2. Understanding Definitions

• Samoan: Refers to a person from Samoa or of Samoan descent.
• Key Points:
  • This category includes people who identify their origin as Samoan, including American Samoa.

3. Coding Instructions

• Steps:
  1. Identify Relevant Race: Confirm that the resident identifies as Samoan from the medical records.
  2. Verify Documentation: Ensure the race is clearly documented in the resident’s demographic information or admission records.
  3. Code Appropriately: Code A1010M as "1" if the resident identifies as Samoan, and "0" if they do not.

4. Coding Tips

• Accurate Identification: Ensure the race is explicitly mentioned and confirmed by the resident or their family.
• Consistent Terminology: Use consistent terminology when documenting and coding the resident’s race.
• Consult Social Workers: If there is any uncertainty, consult with social workers or family members for clarification.

5. Documentation

• Required:
  • Admission Forms: Ensure the resident’s admission forms clearly indicate their race.
  • Demographic Information: Include details about the resident’s race in the demographic section of their medical records.
  • Social Work Assessments: Document the resident’s race in social work assessments and care plans.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the resident’s race through multiple records and consultation.
• Incomplete Documentation: Make sure all relevant admission forms and demographic information are included.
• Assumptions: Do not assume the resident’s race without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: Maria, a 70-year-old resident, identifies as Samoan.
  • Steps:
    1. Review Records: The nurse reviews Maria’s medical records, including admission forms and social work assessments that indicate she is Samoan.
    2. Identify Race: It is confirmed that Maria’s race is documented as Samoan.
    3. Document and Code: The nurse documents Maria’s race in her records and codes A1010M as "1".
  • Outcome: Maria’s race as Samoan is accurately documented and coded, ensuring proper follow-up and cultural considerations in her care plan.

Please note that the information provided in this guide for MDS 3.0 Item set A1010M 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.