OASIS-Central

Process of care data items collected at transfer and discharge points may require the clinician completing the assessment to review the entire care episode, defined as the time since the most recent OASIS assessment, according to the Centers for Medicare & Medicaid Services (CMS) OASIS-C Guidance Manual.

The Guidance Manual states that the purpose of the review is to determine if a condition (e.g., pain, symptoms of heart failure) was present during the episode and whether interventions to address the condition were a) incorporated into the plan of care and b) implemented as part of patient care. It goes on to say, that the review must consider care provides by all disciples during the episode, not limited to care provided by the discipline of the clinician completing the OASIS assessment.

The process of data items completed at transfer and discharged will require a knowledge of patient symptoms, initial and subsequent physicians’ orders, and clinical interventions performed to address patient symptoms across the episode of care. CMS suggests a few different tips to accomplish the evaluation of care episode.

• The care provider may find it necessary to review clinical records, including the plan of care, updated orders, and visit notes
• The agency may elect to create a flow sheet with the appropriate parameters that are checked off on each visit. The flow sheet may provide the needed information, such that a review of the clinical record would be unnecessary
• Agencies using electronic health records could create a report template that could pull the needed information

This article was developed from the OASIS-C Guidance Manual. To see the full text, visit our Resources page