OASIS-Central

Successful completion of the OASIS begins with knowledge of the data set. Study the tips in the OASIS Implementation Manual and the OASIS-C Guidance Manual. Read and understand each data element—the definition, times to complete it, specific instructions, and assessment strategies. Familiarize yourself with the flow and organization of the assessment tools your agency uses. Then, work through some sample patient examples.

The patient takes seven prescribed medications and an aspirin before lunch every day. On Sunday, she fills a pillbox with the doses for that week. This patient is able to manage her own medications, which would be response 0 in M2020, management of oral medications. Six weeks later, the patient falls and breaks her hand. Her daughter prepares the doses using medication cups. The recertification assessment notes response 1, this patient is able to take medications at the correct times if the doses are prepared in advance by another person.

Then you’re ready to put your assessment skills into action. Here are some more tips for using the OASIS as part of the comprehensive assessment:

» Observe the patient’s response or behavior objectively whenever possible.

» Interview the patient or caregiver to determine the responses for some of the data elements.

» Describe the patient’s usual status, that is, the status more than 50 percent of the time during the day under consideration.

» Identify the patient’s ability to perform each activity safely. The clinician must assess the patient’s current ability and then determine the amount of assistance the patient needs to complete the activity safely.

» Complete the OASIS as you assess the patient. You don’t need to start at the beginning and go in order to the end.

»» Complete all desired elements except those that don’t pertain to the patient.

Your patient does not have any surgical wounds, so skip the questions that ask for details about that.

» Pay attention to the instructions. Some data elements require you to mark all the answers that apply; others ask for only one.

» Follow the instructions in the OASIS-C Guidance Manual to complete the data elements. You’ll find qualifying information in some cases.

Determine the patient’s level of vision in M1200, wearing glasses, if the patient usually wears them.

Identify the frequency of the patient’s pain in M1242 that interferes with mobility or activity.

» Avoid the use of “not applicable” or “unknown.”

» Do not refer to previous assessments when updating an assessment. Some questions in OASIS-C ask about the patient’s status at the start of care or whether certain care was provided. The clinician can refer to past documentation in the clinical record, such as visit notes or case conference minutes but he or she cannot review a past assessment.

The nurse or therapist must visit the patient to conduct the assessment in all cases except transfer and unexpected discharge. If the agency does not learn about a discharge until after it happened, the nurse or therapist can complete the assessment based on the last visit by a qualified professional (registered nurse or therapist).

This is an excerpt from  Chapter 3 in The Beacon Guide to Medicare Service Delivery, 2010 Edition by Diane Omdahl, RN, MS.  Chapter 3 details the OASIS assessment, assessment strategies, and when staff must perform the comprehensive assessment.

For more information about The Beacon Guide, click here!