Figure 1: General OASIS Item Conventions 1. Understand the time period under consideration for each item. Report what is true on the day of assessment unless a different time period has been indicated in the item or related guidance. Day of assessment is defined as the 24 hours immediately preceding the home visit and the time spent by the clinician in the home. 2. For OASIS purposes, a quality episode must have a beginning (that is, an SOC or ROC assessment) and a conclusion (that is, a Transfer or Discharge assessment) to be considered a complete care episode. 3. If the patient’s ability or status varies on the day of the assessment, report the patient’s “usual status” or what is true in greater than 50% of the assessment time frame, unless the item specifies differently. 4. Minimize the use of NA and Unknown responses. 5. Some items allow a dash response. A dash (–) value indicates that no information is available, and/or an item could not be assessed. This most often occurs when the patient is unexpectedly transferred, discharged, or dies before assessment of the item can be completed. CMS expects dash use to be a rare occurrence. 6. Responses to items documenting a patient’s current status should be based on independent observation of the patient’s condition and ability at the time of the assessment without referring back to prior assessments. Several process items require documentation of prior care, at the time of or since the time of the most recent SOC or ROC OASIS assessment. These instructions are included in item guidance for the relevant OASIS questions. 7. Combine observation, interview, and other relevant strategies to complete OASIS data items as needed. (For example, it is acceptable to review the hospital discharge summary to identify inpatient procedures and diagnoses at Start of Care, or to examine the care notes to determine if a physician-ordered intervention was implemented at Transfer or Discharge.) However, when assessing physiologic or functional health status, direct observation is the preferred strategy. 8. When an OASIS item refers to assistance, this means assistance from another person. Assistance is not limited to physical contact and can include verbal cues and/or supervision. 9. Complete OASIS items accurately and comprehensively, and adhere to skip patterns. 10. Understand the definitions of words as used in OASIS. 11. Follow rules included in the Item Specific Guidance (Chapter 3 of the manual). 12. Stay current with evolving CMS OASIS guidance updates. CMS may post updates to the guidance manual up to twice per year, and releases OASIS Q&As quarterly. 13. Only one clinician may take responsibility for accurately completing a comprehensive assessment. However, collaboration is appropriate under the One Clinician Rule. The One Clinician Rule became effective January 1, 2018, allowing the assessing clinician to elicit input from the patient, caregivers, and other health care personnel, including the physician, the pharmacist and/or other agency staff to assist them in the completion of any or all OASIS items integrated within the comprehensive assessment document. 14. The use of the term “specifically” means scoring of the item should be limited only to the circumstances listed. The use of “for example” means the clinician may consider other relevant circumstances or attributes when scoring the item.. Note . From Centers for Medicare and Medicaid Services. (2019). Outcome and assessment information set OASIS-D guidance manu al. Effective January 1, 2019. Retrieved from https://www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/ Downloads/OASIS-D-Guidance-Manual-final.pdf
● Data Sources/Resources : Describe the potential sources of information that may be accessed during the assessment to determine the most accurate response to this specific item. Guidance may also include specific guidelines or standards that provide insight into strategies or techniques that can be used for obtaining the information needed. Home health therapists need to spend some time and effort studying each of the 90 OASIS items. There is really no shortcut to mastering the OASIS instrument. To master the guidance in Chapter 3, the therapist should follow these recommendations: 1. Obtain a copy of Chapter 3 and scan through it. Get a feel for how simple or complex the guidance is for each of the different items. 2. As you complete your first several OASIS assessments, carefully review the guidance for each item. Even an item as simple as the patient’s zip code has guidance that you might find necessary. For instance, the response should be the zip code where the patient is obtaining care, not the zip code of the patient’s legal address. 3. Even after you master OASIS, you will find times when a patient’s specific situation challenges your understanding about which of the OASIS responses best applies. When this happens, go back and consult Chapter 3’s guidance for that specific item. 4. You will undoubtedly make errors in your OASIS documentation at times, but the quality review team at your agency will probably find at least some of these errors and The 90 OASIS items are divided into 19 sections (see Table 1). Each of these 19 sections is described below. In order to visualize the items in each section, the therapist should consult the complete OASIS dataset, labeled with the 19 OASIS topics, at the end of this course. Even better, the therapist should review this section with the OASIS-D Guidance Manual ’s Chapter 3. (Download at https://www.cms.gov/Medicare/Quality- Initiatives-
ask you to correct them. When asked to make an OASIS correction, be sure to consult the Chapter 3 guidance again so you understand the error you made and learn how not to repeat it. It is impossible to overstate how important it is to master the guidance in Chapter 3 of the OASIS-D Guidance Manual . Unfortunately, there is no way to master the OASIS and to answer the OASIS items accurately without carefully reviewing the instructions in this document. Inaccuracy in OASIS can have many deleterious effects on an agency. Errors in OASIS can lead to payment denials, poor patient outcome reports, and medical records that would not stand up well if scrutinized in a court of law. For instance, if the therapist inaccurately scores a patient on an OASIS item as having greater functional independence than is actually the case, the agency can be deprived of hundreds of dollars in reimbursement to which it is entitled and which it needs for adequate compensation for the care that has been provided. If the patient is scored as being more functionally independent than he or she actually was at admission, at discharge the patient will not show improvement under the agency’s care even though he or she did improve. This sort of error hurts the agency’s outcomes publicly reported on the Home Health Compare website. Ultimately, when these types of errors have occurred repeatedly, they can have a negative impact on the number of patients and discharge planners who choose the agency for care. Patient-Assessment-Instruments/HomeHealthQualityInits/ Downloads/OASIS-D-Guidance-Manual-final.pdf. In order to complete the OASIS items, the clinician must perform a systems review of the patient. All therapy disciplines (physical therapists, occupational therapists, speech-language pathologists) are educated in complete body system assessments. However, agency practice patterns and state practice acts for agencies may cause therapists to no longer
THE OASIS-D1 DATA SET
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