Step-by-Step Coding Guide for Item Set A1110A: Language: What is your preferred language?

1. Review of Medical Records

• Objective: Ensure comprehensive understanding of the resident’s language preference.
• Steps:
  1. Collect Records: Gather the resident’s medical records, including admission notes, social history, and any previous assessments.
  2. Verify Language Preference: Look for documentation indicating the resident’s preferred language for communication.
  3. Consult Communication Logs: Review any logs or notes from interactions with the resident that might indicate their language preference.

2. Understanding Definitions

• Preferred Language: The language that the resident most comfortably and frequently uses for communication.
• Assessment Item A1110A: An MDS item that records the resident’s preferred language, ensuring that care and services are provided in a manner that is understandable to the resident.

3. Coding Instructions

• Steps:
  1. Locate Item Set: Find item set A1110A on the MDS form.
  2. Ask the Resident: If possible, ask the resident directly, “What is your preferred language?”
  3. Record Response: Enter the language specified by the resident. Use the standard language codes if available, otherwise, write in the language.
  4. Verification: If the resident cannot respond, verify through family members or previous documentation.
  5. Complete Entry: Enter the appropriate language based on the resident’s response or verified information.
  6. Review: Double-check the entry for accuracy.

4. Coding Tips

• Direct Communication: Whenever possible, obtain the language preference directly from the resident.
• Use Interpreters: If there is a language barrier, use interpreters to ensure accurate communication.
• Consistent Documentation: Ensure that the preferred language is consistently documented across all records and forms.

5. Documentation

• Required:
  • MDS Form: Correctly filled entry for item set A1110A indicating the resident’s preferred language.
  • Medical Records: Admission notes, social history, and any communication logs indicating language preference.
  • Verification Notes: Notes confirming the resident’s language preference, especially if verified through family members or interpreters.

6. Common Errors to Avoid

• Assumptions: Avoid assuming the resident’s preferred language based on their background or other characteristics.
• Incomplete Verification: Ensure thorough verification if the resident cannot respond directly.
• Inconsistent Documentation: Ensure the language preference is documented consistently across all records.

7. Practical Application

• Example:
  • Resident Background: Mr. John Doe is a new resident whose preferred language needs to be documented.
  • Review Process: Access Mr. Doe’s medical records, including admission notes and social history.
  • Direct Communication: Ask Mr. Doe, “What is your preferred language?” He responds with “Spanish.”
  • Coding Process:
    • Step 1: Locate item set A1110A on the MDS form.
    • Step 2: Enter “Spanish” in the preferred language field.
    • Step 3: Verify through Mr. Doe’s family or previous documentation if needed.
    • Step 4: Review the entry for accuracy.
  • Illustration:
    • Provide a sample MDS form showing item set A1110A with “Spanish” entered as the preferred language.
    • Include an example of a social history note confirming the language preference.

Please note that the information provided in this guide for MDS 3.0 Item set A1110A 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.